Journal of Psychiatric and Mental Health Nursing, 2010, 17, 700705

Nietzsches Genealogy of Morality and the changing

boundaries of medicine, psychiatry and psychiatric and
mental health nursing practice: a slave revolt?
jpm_1584

700..705

F. C . B I L E Y r n p h d
Associate Professor, Bournemouth University, Bournemouth, UK

Keywords: medical and nursing

paternalism, Neitzche, philosophy
Correspondence:
F. C. Biley
R105
Royal London House
Bournemouth University
Christchurch Road
Bournemouth
BH1 3LT
UK
E-mail: fbiley@bournemouth.ac.uk
Accepted for publication: 15 April 2010
doi: 10.1111/j.1365-2850.2010.01584.x

Accessible summary

The boundaries of medical and psychiatric and mental health nursing practice
appear to be changing in recent years
These changes include a move towards more inclusive health care practices that
recognize common physical and mental corporeality
This may suggest an inversion of the values that were previously held as good or bad

Abstract
The main constructions in Nietzsches On the Genealogy of Morality (1994) are
employed in order to explore the changes in mental health care that have been recently
taking place. Characterized by boundaries that define the objectivity of scientific
method, the biological stratum or the area of concern (disease and the disembodied
being) and the professional distance that is maintained in the healthcare encounter, the
noble morality of contemporary allopathic (Western) mental health care practice
appears to be being challenged, in an act of ressentiment, by the slave morality of society,
inverting values and beliefs that have previously been held. Mental health care paternalism may be in the process of giving way to consumer sovereignty, patient participation in decision making and the re-discovery of the embodied being at the centre of the
healthcare encounter. Nietzsche warns that the dominance of slave morality and the
inversion of moral values (what was a quality that was held by the nobles and regarded
as good) that is, objectivity and mental health care paternalism becomes bad; and
what was a quality held by the slaves and regarded as bad subjectivity becomes good,
may ultimately be detrimental to the advancement of society.

Introduction
People originally praised unegoistic actions and called
them good from the perspective of those for whom they
were done, that is, those for whom such actions were
useful. Later people forgot how this praise began, and
because unegoistic actions had, according to custom,
always been praised as good, people then simply felt
them as good, as if they were something inherently
good. (Nietzsche 1994)
An earlier version of this paper was published in the International
Journal of Human Caring, 8: 2, 2125; and it is re-published here with
the full permission of the Editor, Professor Zane Robinson Wolf.

700

In the book On the Genealogy of Morality, written by

Nietzsche and appearing as an English translation for the
first time in 1967 as On the Genealogy of Morals, the
author explored the subject of moral codes, the basis of
survivalist strategies, which he defined as falling into one of
two categories. These are the moral codes of the nobility,
which is characterized by qualities such as strength and
assertiveness (good, or possessing the qualities of the
nobles) and the moral codes of the slaves, characterized
by qualities and the subsequent emergent activity that
expresses weakness, passivity and dependence (bad, or
rather, lacking the qualities of the nobles). Tension between
these moralities creates a power struggle, and although
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Nietzsche, medicine and the slave revolt

noble morality once dominated, slave morality and their

previously identified qualities are now in ascendancy. What
was once bad now becomes good. Inspired by this purposefully over-simplified interpretation of Nietzsches position,
which originally considered the rise of modern Christian
morality as a result of a slave revolt against earlier noble
dominance, evidence is sought for the re-interpretation of
modern allopathic (that is Western) medical, psychiatric
and mental health nursing practice as a (power) struggle
and an attempt to assert one set of codified behaviour over
another, or rather an inversion of what constitutes good or
bad qualities. Specifically, in this instance, an investigation
will be constructed in order to establish whether there
appears to have been an attempt by the slaves (patients) to
assert their ascribed qualities over the nobility (medicine,
and in particular, psychiatry and subsequently psychiatric
and mental health nursing).

Models, aims and goals of medicine,

psychiatry and nursing
The practice of modern allopathic, Western medicine can
be interpreted in a number of different ways, with each
interpretation generating its own definition. For example,
Gunderman (1995) critically considers the adequacy of the
dominant reductive-isolation model of health and disease,
which is characterized by:
quantification and measurement and aims to peer
beneath variability and subjectivity, and the infinite
variety of patient experiences to something universally
definable measurable and objective (p. 676).

An alternative approach, he suggested, is the larger and

more complex reality of the patient as addressed by [an]
ascendant interrelation view, in which the organism has
an identity that transcends that material with which it
is made (p. 676). Similarly, Tamm (1993) considered a
number of different religious, humanistic and transpersonal
models of health, and biomedical, psychosomatic and existential models of illness and disease. However, taking a
slightly different perspective, in an interesting exploration
of the main themes in Nietzsches On the Genealogy of
Morality (1994) as applied to caring, nursing and the ressentiment of nursings attempt to escape from a state of
slave mentality/reality, Paley (2002) claims that the nature
of medicine and the medical model can be defined by a set
of boundaries . . . (p. 29). These boundaries, which also
seem to define objectivity and represent, and celebrate, the
nobles [medicines] most prized characteristics, the qualities that make them what they are (p. 28), consist of the
scientific method, which defines the nature of legitimate
evidence and perhaps therefore what constitutes knowledge and truth, the biological stratum, which is a
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boundary determining the proper field of enquiry (p. 29),

and the professional distance, indicating the typical
nature and quality of the doctor-patient relationship. If this
definition of medicine, psychiatry, the medical model and
medical-model psychiatric and mental health nursing practice can be accepted, then it can be seen to be characterized
as using evidence that has emerged through a process of
empirical analytical science (Rapport 2002), the scientific
method. It has as its focus a concern the promotion of
health and the elimination of disease in human beings, the
biological stratum; and finally, maintains a professional
distance (and/or emotional detachment) in order to remain
objective. If this defines the nature of medicine and, by
default, psychiatry and psychiatric and mental health
nursing, then their goals can be summarized in a clear and
simple statement that includes reference to all three boundaries. It could be said to be aimed at the objective promotion health and elimination of physical and mental disease
in all human beings by the application of knowledge that
has emerged as result of the processes of empirical analytical science. Superficially, for some this might form the basis
of an acceptable and accurate definition of the goals of
medicine and psychiatry. For many, it may reflect the actual
activity of the medical and nursing professions and the
reality of its practice. However, adopting such a definition
could have limited its effective practice and prompted the
modern allopathic medicine critique and the actual and/or
potential alteration in the boundaries that, it will be
argued, seem to be taking place. This definition of medicine, the medical model and medical-model psychiatric and
mental health nursing can be reduced to one main theme,
that is, the subject of objectivity.

Objectivity or subjectivity?
It has been claimed that the world view of contemporary
medicine is instrumental and scientific, objectifiable and
knowable (Wiltshire 2003). Such a world view leads to
scientific objectivism which fails to acknowledge the complexity of the human condition and recognize that medicine
is not an exact science. Diagnosis and prognosis cannot be
made with absolute certitude (Lim 2002; p. 144). In any
medical encounter, both the psychiatrist/nurse and the
patient have at least one thing in common, that is that they
both possess a human body and mind, that they are
embodied beings (p. 188). However, this:
is an object of knowledge in only one of them. The
construction of medicine seems designed to sever, or
suspend, recognition of this commonality
(Wiltshire 2003; p. 188)

Traditionally, science may be defined as the construction of generalizable statements about how the universe
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F. C. Biley

We were told that our cadaver would be our first patient. I thought that was an
interesting take on the situation. At first glance, my group's cadaver certainly didn't
look human. Her skin had a plastic texture, her insides a muddy gray color rather
than the brilliant reds and blues I naively expected from looking at the textbook
atlases. She looked so small, frail, sexless even. But then I saw a blister on her toe.
And on another cadaver, nail polish. So they were human, once. Still? I'm not sure. I
wish someone would talk to us and help us to deal with the confusion.

behaves (Greenhalgh 1999; p. 323), a view that fails to

recognize the uncertainty produced by the complexity of
the human condition (Gillett 1994; p. 1125). In medicine,
psychiatry and nursing, the practice and application of
pre-Kuhnian traditional science, that which promotes the
idea of there being one single truth (Gillett 1994), is typified by the rigorously defended evidence-based practice
movement, which applies statements of truth (the correct
treatment) that have been established by the empirical
observation of populations in randomized trails and cohort
studies (Greenhalgh 1999; p. 324). Such an objective,
reductive-isolation (Gunderman 1995) approach may have
been fostered in psychiatry through its process of secondary socialization or colonization, which is, as Habermas
(1987; cited in Wiltshire 2003; p. 188) stated, the shaping
of the experiential world of our moral lives by instrumental
rationality, highly routinized procedures, and both technical and technological management (p. 85). Pragmatically,
such an approach is exemplified by a quote from a medical
student, who was being exposed, for the first time, to the
process of cadaver dissection (Fig. 1), to the beginning
process of objectification, of objectivity, to dealing with the
other, another (something) that is not quite, but almost, a
disembodied being.
Good (1994) exemplified the position of objective
detachment in a study of medical students at Harvard and
found that they became isolated from the real world in a
peer-reinforced denial of common (doctor-patient) corporeality (Wiltshire 2003), founded in an ever increasing
concern with learning about and understanding the
mechanical functioning of the body and an exclusion of
what was classed as irrelevant (non-biological) detail. It
could be argued that the growing objectification and denial
of a common corporeality that could be imposed by
medical and psychiatric and mental health nursing training
leads to an inability to recognize humanity and the sacredness of the tasks with which graduates of medical and nurse
training eventually become involved. Could this be the
development of clinical gaze, described as that which:
refrains from intervening: it is silent and gestureless.
Observation leaves things as they are; there is nothing
hidden to it in what is given. The correlative of observation is never the invisible, but always the immediately
702

Figure 1
Carries experiences of dissection (Levin
2000)

visible, once one has removed the obstacles erected to

reason by theories and to the senses by the imagination
(Foucault 1975; p. 107).

If objectivity is the ultimate goal of reductive-isolation

medical and psychiatric and mental health nursing practice,
manifest as perceptions and statements of truth arrived at
through processes of empiric, rational science, disembodiment and the denial of a common corporeal reality, then
practices emerge that do not maximize their potential.
However, they could be seen to represent, and celebrate,
the nobles [medicines] most prized characteristics, the
qualities that make them what they are (Paley 2002; p.
28). Paley (2002) maintains that slaves (nurses) reaction
to this, a revengeful revolt against medical domination, has
been to invest heavily in the ressentiment of the development of an inversion of the objectifying medical model, the
caring (meta)paradigm, in order to attack the evil values
of objectivity held by the nobles (medicine). According to
Paley (2002):
To be objective is a good thing . . . It is only when the
slave revolt occurs that objectivity . . . acquires a moral
weighting. In the eyes of ressentiment, it is transformed
into something evil . . . repugnant, soulless, reprehensible (p. 28).

In a state of ressentiment, medical objectivity (practice)

and the expression of nobility (Paley 2002; p. 31) becomes
positivist (a pejorative term in this instance), reductionist
and mechanistic (Paley 2002; p. 29).
Paley (2002) has constructed a very logical, coherent
and compelling discussion of nursings response to medical
domination. However, it may be considered to be flawed in
a number of ways (Rapport 2002); not least because it
appears to pay little, if any, attention to the sociological
context in which the slave revolt has taken place. Paley
(2002) asserts that the caring slave revolt emerged from the
burst of creativity (p. 33) that followed the expansion of
doctoral programmes in nursing in 1970s USA. Psychiatric
and mental health nursing, and for that matter medicine
and psychiatry, cannot be easily separated from the contextual and inextricably linked sociological soup of humankind that ultimately dictates and must be held responsible
for the nature of allopathic medical, psychiatric and health
care practice. Although perhaps somewhat of an over 2010 Blackwell Publishing

Nietzsche, medicine and the slave revolt

simplification, it could be suggested, for example, that the

expansion of doctoral programmes in nursing in 1970s
USA occurred for some reason. That reason may have been
because of dissatisfaction with the values and subsequent
actions held by practitioners of allopathic medicine (and
included in this is the practice of medical model dominated
psychiatric and mental health nursing) in the general population. If, to expand Paleys (2002) argument, members of
the general population are considered to be the slaves in
revolt against medical and psychiatric domination, rather
than nurses, a different picture might emerge. For example,
the emergence of the caring or humanizing (Todres et al.
2006) (meta)paradigm becomes one manifestation of the
revolt rather than the revolt itself. Such an assertion
requires the search for, and identification of, the revolt
itself, or at least the creative act that represents the revolt.
If, for the sake of the argument in this instance, it is
assumed that it is the general population that can be
defined as the slaves under the control (to some extent this
involves acknowledging, accepting and responding to the
moral characteristics) of the nobility, then this search needs
to centre, at least in the first instance, on the relationship
between the slaves and the nobility and the alteration of
boundaries and any objective practice.
Over 20 years ago one author claimed that the nature of
medicine and psychiatry has changed considerably over the
past 50 years as a result of powerful social forces (Starr
1982), a view that has been expressed elsewhere (Cantor
2001, Berger 2002, Chin 2002). Although some advances
have been made as a result of the development of, say,
medical technology and social policy, commentators have
identified that not all these changes have been positive.
They have gone as far as to say that medicine is a major
threat to health (Illich 1976), with considerable adverse
effects and the perception that conventional treatments are
too harsh (Furnham & Forey 1994), and that the focus on
individualism persist to the detriment of a social understanding of mental health (Pilgrim & Ramon 2009). In
what could be called the beginning of an inversion of moral
values, medicine has, according to Illich (1976), destroyed
an individuals inherent capacity to deal with death, pain
and suffering and he identified solutions to this that
included a need for a health care system that, among
other things, paid attention to patient autonomy (selfdetermination) and promoted self-care. While there has
been a reluctance to accept such criticism in some quarters,
elsewhere there is a growing recognition of the limits of
evidence-based medicine, that threaten[s] the art of medicine and perpetuate[s] medical paternalism (Parker 2002;
p. 273; emphasis added). Others have called for doctors to
participate in the de-medicalization of medicine (Moynihan
& Smith 2002) or run the risk of becoming its most
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prominent victims (Leibovici & Lievre 2002; cited in

Moynihan & Smith 2002). However, this discourse does
not define any boundaries that might have changed, or are
in the process of changing. As it has been previously
identified, objectivity is the ultimate goal of reductiveisolation medical practice, manifest as perceptions and
statements of truth arrived at through processes of
empiric, rational science, disembodiment and the denial of
a common corporeal reality. These practices do not really
identify and adequately respond to the nature of concern of
medicine, psychiatry and psychiatric and mental health
nursing, that is practices that are able to respond appropriately and positively to the human condition.
Societies now demand, at least to some extent, that the
recipients of mental health care are recognized as embodied
beings, with a physical and mental corporeality that is in
common with practitioners of mental health care and
where the material accompanies the affective and the symbolic (Wiltshire 2003; p. 191). This is manifest in a
number of different ways, not least in the ressentimentbased demand being made by society that individuals are
given the opportunity to participate in decision making
about their treatment and care. Such an assertion supports
the view that the boundaries of mental health care may be
in the process of changing.
Wiltshire (2003) has maintained that the pursuit of
autonomy for the patient often in practice results in the
augmentation rather than diminishment of medical [and
psychiatric] power (pp. 191192). However, this perspective only survives scrutiny if it is accepted that it is mental
health care that is driving the pursuit of patient autonomy.
If patient autonomy is being pursued by patients, and/or
those in need of mental health care, as an act of ressentiment, that is a slave revolt against noble morality, then
medical, psychiatric and psychiatric and mental health
nursing power, at least within the patient encounter, will be
diminished.
Authors have expressed concern with the simple rejection of medical and psychiatric paternalism. Such paternalism is one form of doctorpatient or nursepatient
relationship that is characterized by objectivity, pays little
or no attention to patient preferences, where the doctor or
nurse acts as a guardian (Emanuel & Emanuel 1992) and
where the patient passively acquiesces to professional
authority by agreeing to the doctors [nurses] choice of
treatment (Charles et al. 1999b; p. 781). Such an approach
will severely limit the potential of patient participation in
medical, psychiatric and psychiatric and mental health
nursing decision making. Emanuel & Emanuel (1992)
suggested that alternatives, such as the informative, interpretative and in particular, the deliberative model of
doctorpatient (nursepatient) relationship, where the
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F. C. Biley

doctor (nurse), acting as a friend or teacher, enters into

dialogue with the patient in order to illicit and agree values
need to be considered, an idea that has been mirrored
elsewhere (Quill & Brody 1996, Chin 2002). Similarly,
Berger (2002) argues that paternalism, which is more
acceptably re-titled moral authority needs to be employed
to complement sapiental authority (which arises from
competent action) and charismatic-empathic authority
(acting as a friend) in the care of those with chronic diseases. Charles et al. (1999b) identified that restricted time
and funding were barriers to the promotion of patient
participation in decision making, but that different models,
from a range of paternalistic, informed, shared and intermediate options, can be employed according to circumstance, arguing, for instance, that:
In cases where both the patient and doctor [nurse] prefer
this [paternalistic] approach, it can be argued that they
have entered a form of partnership . . .
(p. 781).

Conclusion
Whatever the model of patient participation in decision
making, as it can be seen from this brief excursion into the
medical and psychiatric literature (and there is of course a
wealth of further material and evidence that could have
been employed to explore the subject in more depth), the
subject is certainly on the medical and nursing agenda,
although it seems to be being treated cautiously. The
boundaries of medical, psychiatric and psychiatric and
mental health nursing practice appear to be changing from
objectivity and medical, psychiatric and nursing paternalism towards more inclusive, humanizing and life-world led
(Todres et al. 2006), health care practice that recognizes
common physical and mental corporeality. But does this
represent a slave revolt, a ressentiment, and inversion of
those values that were regarded as good, or bad?
Nietzsches previously unmentioned Priests, who are the
leaders of the slave revolt, are those who are intelligent but
otherwise lack the characteristics of the nobles. In this
instance, it could be said that they are like medical doctors,
psychiatrists and psychiatric and mental health nurses, but
they are not. The Priest, or Priests, are responsible for the
revolt, for guiding the herd to the new morality. If it is
society that is changing the boundaries of medicine and
psychiatry then those in society who could be regarded as
progenitor Priests could be those involved in the service
user, consumer, human, feminist, black and equal rights
movements (see for example Charles et al. 1999a) and the
emergent notion of consumer sovereignty in healthcare
(Charles et al. 1999b). Names might include, but only for
the sake of illustration, Martin Luther King, the Dalai
704

Lama, Dworkin, Malcolm X and John F. Kennedy.

Nietzsche himself may not have taken an exception to such
an assertion, as he stated (from within the context of his
own conceptualization, which was, of course, very different
to the one stated here) that slave morality was in its
ascendancy and that the major source of the revolt was
egalitarian democratic socialism.
However, just at the point when all loose ends should be
satisfyingly brought together in order to neatly conclude
such philosophical/hypothetical meanderings, there is one
final interjection that potentially threatens to subvert the
tentative assertions that have been made so far, or at least
demands further attention than can be given here. A claim
has been made that the Priests of the new (slave) morality
are driving consumer sovereignty in healthcare, the
search for alternatives to objective practice and the reembodiment of the health care encounter; and that the
boundaries of medical practice are changing. Nietzsche
(1994) warned, however, that ultimately the dominance of
slave morality is a threat to the advancement of man and
that noble morality, in either a pre-existing or new form,
needs to be rejuvenated or newly (re-)constructed. It is
tempting, but dangerous (as the suggestion cannot be
expanded according to the orthodox requirements of
academic rigour) and a little too ambitious at this point,
to try to suggest solutions to this emerging dilemma and
to predict the future of medical, psychiatric and psychiatric
and mental health nursing objectivity, but Wiltshires
(2003) assertion that the future of medicine, psychiatry,
nursing and medical morality could be in the profession
adopting some of the moral principles and practice of what
might be considered to be real psychiatric and mental
health nursing (as defined by, for example, Brimblecombe
et al. 2007) might seem to be a tantalizing potential. Such
a solution would satisfy those who demand consumer sovereignty, re-instate the embodied being at the centre of the
healthcare encounter, and offer a re-inversion of those
qualities that were once regarded as good (or bad) and
subsequent noble re-domination.

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