Volume 2, Issue 4 - June 1999

Considering The Limits Of A Care Ethic

It has been suggested that an ethic of care, or a care ethic as it has come to be called, is the best kind of ethic for health professionals, especially nurses, to adopt. The main premise of the care ethic is that caring is not only the ideal way of interacting with others; it is all that is necessary for engaging in ethically sensitive and responsive practice, including making decisions and taking actions in behalf of another. Now, within a care ethic it is recognized that it is unrealistic to expect anyone to have a true caring relationship with every person to whom they owe a moral responsibility.^1,2 This reality leaves followers of an ethic of care to question what should guide their interactions with another when the moral agent does not yet experience caring for a particular person. To deal with this reality, a care ethic declares that a person who holds caring as the ethical ideal will act as if he or she cares while attempting to develop a true caring relationship with them.^1,2

Many arguments have been presented cautioning individuals and health professionals against exclusively adopting a care ethic in their daily personal and professional lives. I will attempt to sketch some arguments which illustrate that a care ethic is an inappropriate ethic to adopt for two reasons. First, even if a person could care for everyone to whom a moral responsibility is owed, simply caring for others is not enough;^3,4,6 experiencing others only through the lens of care involves a morally impoverished way of seeing, experiencing, and responding to others.^4,6 Second, adopting an ethic that holds care as the sole or even the central precept can result in harm to those who use the ethic and those involved with them.^5,6

Before I continue I feel it is important to emphasize that these arguments do not mean care should not be part of an ethics theory; the arguments only serve to illustrate, as I have presented elsewhere, that an integrated ethics theory is a more substantial ethic to use in professional education and practice than a care based ethic.⁶

Too Narrow A Moral Sensitivity

There are three limitations of an ethic of care that contribute to its necessarily involving a morally impoverished way of experiencing and responding to others. First, from a stance of caring, the professional is guided to see and experience the other person only as someone for whom the professional cares (or should care). Second, the only moral obligation professionals would believe they owed another is to act as if they care and pursue caring for the other. Third, engaging in ethical practice would be viewed as contingent on caring.

A care ethic, essentially, does not guide a professional to foundationally see the other as a unique, irreplaceable person who deserves to be treated with an informed ethical sensitivity and responsiveness, simply because of being a person.^4,6 Development of this moral sensitivity emanates from the moral precept of respect for persons.^4,6-8

It is often acknowledged that respecting another as a person leads to being able to care for that person, and that caring is a specific way of experiencing another person that will add an additional dimension to the already present relational experience.⁹ However, it has not been made explicit in present-day health ethics discourse that respecting another as a person and caring for a person involve two distinct ways of seeing and experiencing others.⁶ In fact, some have referred to caring as the same as respect¹⁰ while others suggest respect is implicit in caring;^2,7 two claims that experience and investigations reveal are false.

Reflecting on experiences with others helps us to uncover that when we see a person through the lens of respect our responsiveness toward that person has a richness that is often referred to as "caring", even though caring is not the connection we are experiencing with that person. Reflection also uncovers that we can realistically experience all others through the lens of respect, and that when we engage the moral sensitivity to seeing another as a person, a strong internal force arises within that compels us to be responsive to the individuality of the person - a force different from, but not inferior to, the force exerted through caring.

Hence, a serious, systemic defect of a care ethic is the exclusion of the moral concept of respect for persons. The care ethic lacks a foundation for guiding professionals to develop the sensitivity for seeing all people (including the self) as unique, irreplaceable persons, each with an intrinsic moral worth and deserving of being responded to with ethical sensitivity regardless of whether connection of caring exists or not.

Harm to the Health Professional

Professionals can be harmed by following a care ethic, because the restricted lens of care suggests that caring is the only way a professional can engage in ethically sensitive and responsive practice with patients and others. The harm occurs in at least two ways: from professionals overtaxing themselves in trying to engage in their professional practice through caring; and through the guilt and anguish that results from not being able to meet the imperative to care.

There are indications, uncovered through discussions with nurses, that guilt and anguish contribute to experiencing what I have come to refer to as "moral blunting."⁶ This experience appears to be related to nurses being left to chastise and characterize themselves as lacking ethical competence because they are unable to meet the imperatives of a care ethic, an experience that exists within what is commonly referred to as "burnout".

These ways of being harmed, I suggest, could be alleviated if it was accepted that all that is realistically possible and morally justifiable is for health professionals to express respect for all patients and others as persons, coupled with expressing an openness to care in most relations with patients and others.

Harm to the Patient and Others

The individuals involved with professionals who follow an ethic of care can also be harmed in at least three ways. The harm is caused by developing beliefs that: 1) a person only has moral worth if they are cared for by someone; 2) caring is all that a health professional owes others; and 3) the only way a patient can be assured the professional will engage in ethically responsive practice is to be someone the professional cares for or could come to care for.

The basis of this harm could, again, be alleviated by respect being seen as foundational to ethical practice. This sensitivity would not only enable professionals to develop the abilities necessary for attending to the uniqueness of the person, it would enable patients to experience that health professionals can be trusted to engage in ethically responsive practice.

Closing Thoughts

By being open to the possibility that actually caring for the patient is not necessarily required for engaging in the sensitive and responsive practice often perceived and referred to as "caring", I suggest that we will be enabled to investigate what really is foundational to the responsiveness health professionals need in engaging with patients and each other. This openness may also make it possible for ethics discourse to be less hampered by the often chaotic language of care.

References

• Noddings, N. (1984). Caring. Berkeley, CA: University of California Press.
• Watson, J. (1988). Nursing: Human science and human care. New York: National League for Nursing.
• Kuhse, H. (1993). Caring is not enough: reflections on a nursing ethics of care. The Australian Journal of Advanced Nursing, 11(1): 32-41.
• Callan, E. (1992). Finding a common voice. Educational Theory, 42(4):429-41.
• Carse, A. & Nelson, H. (1996). Rehabilitating care. Kennedy Institute of Ethics Journal 6(1): 19-35.
• Hoopfer, D.L. (1998). Advancing an integrated ethic for nursing. Doctoral dissertation. Faculty of Education, University of Alberta. Edmonton, Alberta.
• Dillon, R.S. (1992). Care and Respect. Canadian Journal of Philosophy, 22(1): 105-132.
• Downie, R.S. & Calman, K.C. (1987). Healthy respect. London, England: Faber and Faber Limited.
• Gilligan, C. (1982). In a different voice. Cambridge: Harvard University Press.
• Gaut, D. (1983). Development of a theoretically adequate description of caring. Western Journal of Nursing Research, 5(4): 313-324.

Donna can be contacted through e-mail: kada@compusmart.ab.ca.  

Announcements

• The Network office is currently in the process of compiling a resource page for the PHEN website profiling the work of Albertans who are completing or have completed theses, dissertations or research projects in the area of Health Ethics. If you have undertaken such a project and would be willing to share this with other Albertans through the Network, please contact Frances Brennan at the Southern Alberta PHEN office by phone, or by email at fsbrenna@acs.ucalgary.ca.

• Audio tapes of the plenary and small group sessions from PHEN's 1999 Annual Conference "When Values Collide: Relationships, Rights and Responsibilities" may be borrowed from PHEN's Northern Alberta Office. To purchase any of these tapes, please contact Kennedy Recordings at (888) 486-1335.

• PHEN Staff Notes:
  • PHEN's Southern Alberta Office has received federal funding to hire a research assistant for the summer. Frances Brennan, a philosophy student pursuing a Master of Arts degree with the University of Calgary will be taking on this position. The Network staff welcome Frances and anticipate a summer of productive collaboration!
  • Susan Cox and Shelley Bakus, the administrative staff from the Network's Southern Alberta Office, will be moving on from the Network. Susan will be pursuing other opportunities related to her home-based business and will continue to provide PHEN with intermittent administrative support. Shelley is leaving to take on a career-related position in the film industry. We will miss them both and wish them every success in their future endeavours.

 Appointments to the PHEN Board

At the PHEN AGM, held this year in Red Deer on May 21, members of the Network elected two new individuals to the PHEN Board. We are very pleased to welcome Gregor Wolbring and Mary Lou Cranston into the PHEN fold and look forward to their contribution in guiding the work of the Network. Members of the Network wishing to contact Mary Lou may do so through the St. Joseph's College Ethics Centre at (780) 439 - 2422. Gregor may be reached by telephone at (403) 220 - 5448, or email at gwolbrin@ucalgary.ca. 

Reminder

Did you know that PHEN is now a registered charity? Anyone interested in supporting the Network's activities through charitable donations may contact either Network office for more information.

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.