“Treat the patient, not the protocol” – Dr. Walsh, THE PITT (2025—)
In today’s post, I am following up on the ideas of the controversial German philosopher, Martin Heidegger in relation to Systems Thinking. This will be a series of posts. See Part 1 here.
In the last post, I discussed the ready-to-hand nature of ‘Systems’, which is based on Heidegger’s earlier ideas. Today, I am exploring his later concepts. I will use an Emergency Room as an example, inspired by ‘The Pitt’ on Max—a medical drama set in a Pittsburgh hospital that illustrates many of the concepts we are discussing. The show explores complex issues faced by both staff and patients, and I highly recommend it.
Beyond Hard Systems Thinking
The general notion of Systems Thinking is to use it to understand and address problems in a system. Some view this as identifying a goal state and developing a map toward achieving that state. Others might reduce it to drawing boxes and arrows. These approaches involve seeing interconnected elements of a system and making changes to improve efficiency or solve problems. In this view, a system is something external that can be fixed or adjusted.
If we follow Heideggerian ideas, however, we begin to challenge the notion of system as an object to be controlled. His philosophy helps us reimagine systems thinking not as a mechanism for optimization, but as a way of engaging with the world that prioritizes reflection, inclusion, and emancipation.
This reimagination sets the stage for fixing the notion of ‘fixing the system’.
Fixing the Notion of Fixing the System
We often point at the physical artifacts of a system and conclude that the system itself is a physical thing “out there.” When something goes wrong—be it biased decision-making, inefficiency, or inequality—the focus is typically on fixing the system. We might say we just need to identify and correct inefficiencies, include more stakeholders, or model it better.
This approach assumes that the system itself is something that can be analyzed, optimized, and managed. The system is seen as an object to be controlled, which Heidegger warns can lead us into a technological mindset he called ‘Gestell’. This German word can mean a physical shelf, rack, or framework in everyday usage. Heidegger used it to refer to how modern technology frames our approach to the world.
In his critique of technology [1], Heidegger explains that modern technology enframes the world as ‘standing-reserve’—a view where everything, including people and natural resources, is seen as a resource to be optimized, controlled, and efficiently managed. For Heidegger, this mode of seeing the world is pervasive in modern life. It is not merely a matter of wrong ideas or flawed methods; it reflects a deeper shift in how the world reveals itself to us.
In systems thinking, this means that even when we attempt to fix systems, we may still be working within the same way of thinking. We focus on models and boundaries, still seeing the system as something external that can be engineered and controlled. According to Heidegger, we cannot escape this framing by simply improving analytical methods; instead, we need a shift in understanding how the world reveals itself to us—a shift that cannot be engineered or willed into existence, but one that we must arrive at organically.
Recognizing this leads us to ask: if fixing the system is not the answer, what is? It is here that we move from a mindset of control to one of care.
From Control to Care
For Heidegger, the hope lies not in better models, but in a new beginning of thinking. Rather than treating the world and systems as collections of problems to be solved, this approach encourages us to engage with the world as a field of beings to care for. This means approaching the world not as a collection of objects to manipulate, but as a web of interconnected, living entities, each with intrinsic value and meaning.
This shift has practical implications for systems thinking. It means stepping back from the drive to “fix” the system and instead focusing on how we frame the system in the first place. It is about asking, “Who defined the system, and what is concealed by that definition?” This questioning resists Gestell and pushes us toward a more open, reflective, and inclusive approach to systems. This approach aligns with the soft systems thinking school pioneered by Churchman, Vickers, Checkland, Ulrich, Jackson, and others.
Boundaries and Emancipation
From this viewpoint, system boundaries are contingent. Every boundary drawn includes certain aspects while excluding others, and these decisions are made by those who defined the system. For example, in healthcare, a system might be narrowly defined to include only hospitals and doctors, or more broadly to include public health and social factors. The boundaries are not neutral; they reflect values and interests.
We require critical reflection regarding who holds the power to define the system and who are the winners and losers within it. This leads us to focus on emancipation, which involves challenging dominant framings of the system and reimagining boundaries to be more just and inclusive. It is about opening up the framing process to empower marginalized voices and create a more diverse, equitable, and inclusive system.
In the Heideggerian essence, this is about liberating systems thinking from being a tool of control to becoming a process of unveiling and co-creating alternative futures. This involves letting go and being receptive to the world around us, allowing things to emerge and reveal themselves without immediately trying to control or optimize them. Heidegger advises us to shift our attunement—to change how we approach systems. Instead of seeing systems as mechanical entities to be fixed, he encourages engagement that is more reflective, inclusive, and humane.
Letting Go of Control
When we talk about “letting go” in systems thinking, we refer to relinquishing the desire to control or optimize systems in the traditional sense. In much of traditional systems thinking, there is strong emphasis on identifying the “right” model, fixing inefficiencies, and controlling outcomes, often with the mindset that the system can be “engineered” into something better.
However, Heidegger’s perspective asks us to let go of this drive for mastery and optimization. Instead of focusing on fixing the system, he encourages us to focus on how we relate to it—shifting attention away from controlling outcomes toward engaging with the system in a more reflective, open, and inclusive way.
‘Letting go’ is not about giving up on making things better, but about releasing the impulse to always have a fixable or controlled solution. It is about recognizing that systems are complex, messy, and sometimes unpredictable, and that meaningful change often comes from attuning to these complexities rather than imposing rigid solutions.
An Emergency Room Example
Consider an overstretched Emergency Room suffering from long wait times, staff burnout, and patient dissatisfaction. The traditional approach might focus on optimizing wait times, improving throughput, or redesigning workflows—all within the same Gestell mindset of optimization and control.
A Heideggerian approach would invite us to engage with the ER as a shared world, not just a system to be fixed. We might ask:
- What does the ER mean to those who work and visit here?
- What are the invisible boundaries that shape this system?
- Who gets to define what a “good day” in the ER looks like?
By creating space for these questions, we allow the ER to disclose itself in a way that invites reflection and co-creation. This approach might lead to solutions that do not just optimize efficiency but also restore dignity, care, and trust.
We begin to see the hospital not just as a system to optimize or a place where resources are managed, but as a place where people—patients, doctors, nurses, janitors—are engaged in a shared, living experience. Instead of focusing solely on throughput and efficiency, we listen to the experiences of all involved, understand their needs, and respond with care.
‘The Pitt’ portrays this attunement through scenes where ER staff focus on the human elements of care—pausing to notice the little things, the moods of patients, the tone of voice of colleagues, and the atmosphere in the waiting room.
Final Words
Ultimately, integrating Heidegger’s critique of technology into systems thinking teaches us that true emancipation is not about better control over systems. It is about freedom from the need to control systems. The real shift comes not from improving models or creating more inclusive diagrams, but from a new beginning of thinking—one that is more reflective, inclusive, and ethical in how we frame and engage with the systems around us.
In the last and final post of this series, I will examine Heidegger’s thoughts on Cybernetics.
I will finish with a quote from Heidegger [1]:
Enframing not only conceals a former way of revealing, bringing-forth, but it conceals revealing itself and with it That wherein unconcealment, i.e., truth, comes to pass.
Heidegger is warning us of the most insidious danger of Gestell. Gestell does not just hide what is revealed, but it also hides the very process of revealing. It is like wearing glasses that distort our vision, but it also makes us forget that we are wearing the glasses.
Always keep learning…
[1] The Question Concerning Technology and Other Essays, M. Heidegger, translated by William Lovitt, 1977.
Note:
In referencing the work of Martin Heidegger, I want to acknowledge the deeply troubling fact of his affiliation with the Nazi party. This aspect of his life casts a long and painful shadow over his legacy. While I draw on specific philosophical ideas that I find thought-provoking or useful, this is not an endorsement of the man or his actions. Engaging with his work requires ethical vigilance, and I remain mindful of the responsibility to not separate ideas from the broader context in which they were formed.
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Harish's Notebook - My notes... Lean, Cybernetics, Quality & Data Science. 
Years ago, I did an interesting workshop – at least, some of the participants thought so – about facilitating next renaissances (I like to agree with Von Foerster). The issue was that, like a midwife, we cannot control a birth process. As a facilitator I’ve got no power over the resulting result. Not over the beginning, the purposes, not over the end results.
One of the participant didn’t agree with me, and thought he could have the better of me, through presenting me with a children book with “Emergency Vehicles“. As I’m schooled in the psychology of metaphors, we tacitly always “choose” a fitting metaphor, I immediately noticed that this was exactly fitting: “emergent systems require emergency vehicles”. To do so, requires “immergence”, actually the ability to “get lost”.
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The problem with efficiency is that it isn’t very efficient. When one wants to be “efficient”, one invokes boundaries, systems and power & control. You have to set up a “cost accounting system” which is litteraly “non value added”.
Also, calculations are usually good, but the assumptions in cost accounting, make you take the “wrong” decisions. This gets worse, when you, in your health budget, don’t make a distinction between money for investements and expenses.
In health care, we cannot have efficiency, nor so-called “markets”. When “market thinking” was introduced in The Netherlands to reduce the rising EXPENSES (usually presented as “costs”) and to deal with sharing the burden, the growth of expenses grew faster. Paper is patient, if you get the joke.
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I may have told you, that, on studying in my first year of Biophysics, a fellow student asked our professor about the efficiency of photosynthesis. The poor man became confused and asked: “how do you mean, in the spring or in the autumn?”. At that moment I was cured from eficiency thinking.
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That is an awesome comment. Loved the story about the professor and the one about emergency vehicles. I have seen “emergency” used in the context of “emergence”. It was on my list of things to look at the etymology.
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(Please excuse me for the long reply, your remarks made me think)
In his book “Creating Paths of Change“, Will McWhinney takes how one perceives reality as a starting point. He uses four “archetypical” reality perceptions: Sensory (this world consists of facts), Unitary (things are defined according to rules and principles), Social (we, the people, matter) and Mythic (we create the world through ideas, dreams, stories, …).
Within one reality perception nothing changes. He calls a combination of two a Mode of Change. So in this model, there are six modes of change. The most common is “Analytical“, combining Sensory and Unitary (testing and designing). Language comes from the Authoritative mode, Unitary (grammar, rules) <—-> Mythic, (ideas into words).
The path least used he calls “Emergent“, combining Social and Mythic. This can be labelled “Evoking”, Social –> Mythic or feelings and emotions into ideas, and “Facilitating” mythical –> social or ideas to the people. The latter can be called brainstorming and clustering ideas.
I like to call Analytical and Emergent are a paradoxical pair. When rationality doesn’t work, use Irrationality (I prefer unrationality, but then again, I work from a mythic perspective) and vice versa. Here you can see the tension between thinking in systems (parts making up a system, “first order cybernetics”) and systems thinking (making up a system from parts, “second” order cybernetics).
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You can see how to combine the modes in an ER. We’re all human beings. We’re framed into roles, according to our reality perception in a situation.
In ER, one starts from Sensory (facts, having symptoms) to Social (feelings) and from Social to Sensory. Will calls this the “Evaluative” mode (Sensory <—-> Social), what you could call “taking care” and “being taken care of”. One human being becomes a patient, the other a nurse.
Other – or the same – human beings, work more Inductive (Sensory <—> Mythical) to establish the potential causes. It may look analytical, but as the TV series House MD showed (patients lie, symptoms are real), it’s more intuitive.
The patient becomes “a case”. This can be done by somebody “made into” a nurse, and by some one having become a physician. The latter then has to switch modes into “Influential” (social – unitary) persuading <—-> converting the patient to “get the message” (diagnosis) and take the cure. This requires an intermediate step: either using Assertive mode (authority, usually becoming a doctor) or Emergent (evoke, for instance, like nursing – they tend to use relatives… ). Here effectivity rules.
People made into managers (they could have been nurses, doctors or graduates…), use the Analytical and Assertive modes, translating “cases” into “costs and benefits”. Here efficiency is king.
I elaborated on this, because here you can see the dilemma’s (actually paradoxes) of becoming “immersed”: you’re temporarily loosing your identity. Letting go. Shifting perspective requires letting go of who you think you are in a situation AND re-establishing your relationship. (I now understand why in the TV-series, House visits the patient only when he is sure of the “case”. And always runs into trouble with the management).
At the same time, in any situation, there are differences in status and power. These invokes the “double binds”. As a patient, you’re expected to have patience. This is a “down position” – often lying down. As an helper, you’re supposed to help the patient. This is an “up position”, – standing up.
Changing position, required for changing roles, induces doubt and uncertainty. You could say, you have to become an human being, and then move to another position and take up a role.
This shows the challenge of a facilitator: you have to be present and present yourself as what’s required by the situation.
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