Three versions of an ethics of carenup_415 231..240
. Edwards PhD M.Phil BA(hons)
Professor, Department of Philosophy, History and Law, School of Health Science, Swansea University, Swansea, UK
The ethics of care still appeals to many in spite of penetrating criticisms of it which have been presented over the past 15 years or so. This paper tries to offer an explanation for this, and then to critically engage with three versions of an ethics of care. The explanation consists firstly in the close affinities between nursing and care. The three versions identified below are by Gilligan (1982), a second by Tronto (1993), and a third by Gastmans (2006), see also Little (1998). Each version is described and then subjected to criticism. It is concluded that where the ethics of care is presented in a distinctive way, it is at its least plausible; where it is stated in more plausible forms, it is not sufficiently distinct from nor superior to at least one other common approach to nursing ethics, namely the much-maligned ‘four principles’ approach. What is added by this paper to what is already known: as the article tries to explain, in spite of its being subjected to sustained criticism the ethics of care retains its appeal to many scholars. The paper tries to explain why, partly by dis- tinguishing three different versions of an ethics of care. It is also shown that all three versions are beset with problems the least serious of which is distinctiveness from other approaches to moral problems in health care.
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Keywords: ethics of care, Gilligan, Tronto, Gastmans, Little.
Introduction
In spite of telling criticism (Allmark, 1995; Kuhse, 1997; Paley, 2006) the ethics of care retains its appeal
Correspondence: . Edwards, Professor, Department of Philosophy, History and Law, School of Health Science, 7th floor , Swansea University, Swansea SA2 8PP, UK. Tel.: + 44 0 1792-295611; fax: +44 0 1792-295769; e-mail:
to many scholars within nursing and beyond (Tronto, 1993; Gastmans, 2006; Hewitt & Edwards 2006; Grif- fiths, 2008). There are historical reasons for its popu- larity in nursing. These stem from a line of thought according to which while ‘curing’ defines medicine, ‘caring’ defines nursing (cf. Liaschenko & Davis, 1991). As the two disciplines were defined in these terms, it was believed to be plausible by many that while an ethics of principles was appropriate for medicine and its practice, an ethics of care was most
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Original article
232 . Edwards
appropriate for nursing and its practice. This emphasis on an ethics of care was fuelled even further by the fact that in its early versions, a gendered element was present within the ethics of care such that it is an approach to ethics associated with females as opposed to males. This sat well with perceived gender distributions stereotypically associated with medicine and nursing according to which medicine is male dominated and nursing female dominated. Thus we find that Fry writes of principle-based approaches to ethics that they ‘espouse a masculine approach to moral decision making and ethical analysis’ (Fry, 1989, p. 93), the implication being that this thereby renders them inappropriate for application to the nursing context.
As mentioned, in spite of the criticism to which ethics of care has been subjected, its appeal remains. Part of the explanation of this stems from the vague- ness of an ethics of care about which many commen- tators and critics have complained. But a further explanation for the continued appeal of the ethics of care stems from the fact that since the early work done by Gilligan (1982) and Noddings (1984), subse- quent commentators have produced versions of an ethics of care which differ significantly from the ear- liest versions of it. Because of this, it is now plausible to think of ethics of care in terms of three broad types. I take these to be represented by the work of Gilligan (1982); Tronto (1993); Gastmans (2006); also Little (1998).
Version 1: Gilligan (1982)
As Gilligan’s presentation of an ethics of care has been described many times, I will not spend much time doing so. Roughly, Gilligan’s idea is that it is possible to identify two different approaches to moral problems. One approach is described as an ‘ethics of justice’ and another, an ‘ethics of care’. In an ethics of justice moral problems are approached in the same way in which other kinds of problems are approached: they are analysed, competing principles are weighed up, and a conclusion drawn. Cool, impar- tial deliberation is the prevailing feature employing abstract moral principles, such as ‘do not steal’, and ‘protect human life’. In a situation in which there is a
clash between these, the person adopting the ethics of justice works out which is the most weighty and acts accordingly.
By contrast, in an ethics of care, one focuses ‘further in’ on the problem as opposed to ‘abstracting out’ relevant moral principles. Thus one considers contex- tual factors such as the nature of the relationships between those involved in the problem. One seeks to preserve these relationships and to engage with their emotional registers.
Critics have complained about the lack of clarity in the core concept of an ethics of care, namely care itself. Several commentators (e.g. Allmark, 1995; de Raeve, 1996; Paley 2006) point out that the term can be used, perfectly properly, in a way which implies little emotional attachment, e.g. one might agree to care for one’s neighbour’s cat while she is away, or water her plants. One might do this but have no emo- tional attachment to the cat or to the plants. Similarly, a nurse might care for patients in this sense, in which ‘Alex cares for x’ means little more than that Alex looks after x – be x his patients, his neighbour’s cat or his neighbour’s plants – in the absence of any emo- tional connection with x. A further sense of care iden- tified by commentators is that in which, in contrast to the sense just identified, its use does signify emotional involvement with that which is cared for. Hence, this is the sense of ‘care’ which is likely to characterize one’s relationship to those closest to one. And of course, one might say the same of a nurse who is especially caring, in this sense, towards his patients.
It might be maintained that this ambiguity is not fatal in any way to an ethics of care. Suppose this is accepted, at least two further problems remain, each of which seems serious. The first is that, as Allmark has explained, in order for an action or mental state to be morally defensible more is needed than that the mental state or action stems from care (Allmark 1995, p. 23). To illustrate this point, it is feasible to suppose that a parent wakes his 10-year old son up at 05:00 h every morning and compels the child to go through a punishing fitness programme, which always termi- nates with a cold bath. The parent genuinely claims to be acting in the best interests of the child and to be subjecting the child to the fitness regime because he cares so much about his son. Here the parent’s mental
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states and actions stem from care, care for his son. Yet, plainly it does not follow from this that they are ethi- cally defensible. Many other parents might think the parent is cruel, rather than caring. This example shows that the fact that an action or a mental state is char- acterized by care is not sufficient for either to be ethically defensible. To quote Allmark: ‘what we care about is morally important, the fact that we care per se is not’ (Allmark 1995, p. 23).
The second problem is that the ethics of care, in this first manifestation, seems to eschew commitment to a formal principle of justice according to which ‘equals should be treated equally and unequals unequally’ (Beauchamp & Childress, 2009, p. 242). Or as stated by Singer a principle of equal consideration of inter- ests such that ‘we give equal weight in our moral deliberations to the like interests of all those affected by our actions’ (Singer 1993, p. 21). Although, as pro- ponents of an ethic of care point out, our emotional response would lead us to give priority to the interests of our loved ones, and ourselves, this kind of ‘partial- ism’ looks problematic as an approach to ethics. This is because partialism, seemingly arbitrarily, attaches greater weight to the protection of one’s own interests above protection of the interests of others – especially those who are moral strangers. Critics complain that no such partialist approach to ethics can be plausible (Kuhse, 1997). To see why, suppose you are a teacher and your daughter is a pupil in the class. You know she has worked hard to prepare for a class exam paper, which you are marking. She needs to pass the exam in order to secure a place in college. You give her a higher mark than she deserves, simply because you care about her – you are seeking to protect and promote her interests. However, of course, to most of us such behaviour would seem unethical. This is because it runs counter to the impartialist constraints on ethical decision making described above. A student whose work was of the same quality as that produced by your daughter but to whom you give a lower mark can claim to be have been treated unfairly – a complaint almost all of us would recognize as legitimate. This shows that impartialism is not an optional extra in approaches to ethics, but is plausibly regarded as an essential element of them. As will be seen shortly, even those very sympathetic to this first
wave of care-based ethics came to recognize this, and abandoned the view that an ethics of care is of a fundamentally different kind than an ethics of justice.
Version 2:Tronto (1993)
As mentioned above, an approach to ethics which jettisons commitment to impartialist constraints on action and distribution such as the principle of justice does not look promising. Some of those persuaded that there is something novel and important in the ethics of care developed a version of it in which justice is not jettisoned. Thus e.g. Tronto states of a plausible version of an ethics of care ‘. . . a theory of justice is necessary to distinguish among more and less urgent needs’ (Tronto, 1993, p. 138). Her clear implication is that in at least some contexts it would not be justifiable to attend to less urgent needs and neglect more urgent needs even if one is emotionally more distant to the person(s) with the more urgent need.
In addition to incorporating a role for justice, Tronto also sees a place for a ‘universalist moral prin- ciple, such as: one should care for those around one or in one’s society’ (Tronto, 1993, p. 178). This looks like a further departure from the kind of approach devel- oped by Gilligan as the focus there is against ‘univer- salist principles’ and in favour of a more contextualist approach. Also, perhaps in yet further contrast to Gil- ligan, Tronto tries to develop an ethics of care as a contribution political philosophy. Thus she argues that if we focus on caring relationships and the relation- ships between power and caring practices, such as bringing up children and caring for the sick, a radi- cally different set of social arrangements will ensue. While the line of thought that Tronto develops in this way is of interest, it would take us too far away from specifically nursing concerns to pursue it here, there- fore in the exposition of Tronto’s version of an ethics of care I will focus predominantly on its application in the nursing context.
So given that, in apparent contrast to Gilligan, Tronto is explicit that justice must feature in a cred- ible ethics of care, it looks plain that her approach is immune to criticism on that specific point. To start to
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Three versions of an ethics of care 233
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describe Tronto’s approach, we can begin with the definition of care that she offers:
On the most general level we suggest that caring be viewed
as a species activity that includes everything we do to main- tain, continue and repair our ‘world’ so that we can live in it as well as possible. That world includes our bodies, our selves and our environment, all of which we seek to interweave in a complex, life-sustaining web. (Tronto, 1993, p. 103)
In the context of nursing scholarship, readers may well detect some similarities with Benner and Wrubel’s work on care in the description of care given in the definition (see Benner & Wrubel, 1989). However, what does need to be said is that the definition looks extraordinarily cumbersome and complicated. This problem is exacerbated as it is conceded by Tronto that ‘care consumes much of human activity’ but that ‘to play, to fulfil a desire, to market a new product or to create a work of art is not to care’ (p. 104). This is puzzling as one would think at least that play contributes to our living well, and even ‘marketing a new product’ might do the same if the product is, say, a product to help clean up polluted water to make it safe to drink. So in common with other commentators who have tried to define care, Tronto’s attempt does not get off to a promising start.
However, there are some interesting aspects of Tronto’s version of an ethics of care and I will now try to describe these and assess them. The way in which she tries to articulate a distinction related to that which Gilligan draws between ethics and justice, but without neglecting a role of the concept of justice, is to distinguish between what she terms obligation-based ethics, and responsibility-based ethics (see also Gilli- gan, 1982, pp. 73–74). Traditional approaches to ethics, it is claimed, are obligation based. Thus, the sugges- tion is, in moral decision making when considered from the perspectives of utilitarianism, deontology or Beauchamp and Childress’s ‘four principles’ approach (Beauchamp & Childress, 2009), the deci- sion maker works out what obligations, if any, they might have to respond to a situation and then responds accordingly. Such a position is underpinned by an ontology of the person such that humans are
typically separate, independently living, autonomous beings defined in terms of their own, autonomously chosen, moral projects.
By contrast, in responsibility-based ethics the initial starting point of the human is relational involvement with others. The difference this makes in terms of the moral domain is that one’s ‘starting point’ so to speak is one of involvement with others rather than separation from them. And so, the corre- sponding moral presupposition is responsibility for others. So if one witnesses or hears of another’s mis- fortune one’s initial disposition is one of responding to the plight of the other person. Instead of asking, ‘what, if any, obligations do I have to help that person? One asks ‘How can I help?’ one asks this because one is already involved with them, and not separate from them.
To express Tronto’s distinction slightly differently, in responsibility-based ethics there is claimed to be a pre-existing moral relationship between people, and so responding to their plight is ‘automatic’ not in need of justification. But in obligation-based ethics, because one’s initial relationship with others is sepa- ration, not involvement, one will only respond if one recognizes an obligation to do so. So in obligation- based approaches, responding to others involves a ‘two-stage’ process, a first in which one is made aware of the plight of another person, and a second in which one deliberates over which obligations one has towards them – if any. But in responsibility-based approaches, the awareness and the disposition to respond are combined. Hence, Tronto states that an ethic of care involves ‘a habit of mind to care’ (Tronto, 1993, p. 127), not simply to be emotionally moved by the plight of others but to be orientated to help them too. To quote Tronto again: ‘The moral question an ethic of care takes as central is not – What if anything do I (we) owe to others? but rather – How can I (we) best meet my (our) caring responsibilities’ (Tronto, 1993, p. 137).
That distinction is helpful to signal what is novel in Tronto’s approach. But obviously further detail needs to be added to the point about the basic ethical ori- entation. In addition to what she says about that, Tronto goes on to explain that she conceives of an ethics of care as a practice. Thus she writes:
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Care is . . . best thought of as a practice [which involves] . . . both thought and action, that thought and action are interrelated, and . . . are directed to some end. (Tronto, 1993, p. 108; cf. van Hooft, 1995)
As part of this practice, Tronto proposes ‘Four phases of caring’ (Tronto, 1993, p. 105) and also ‘Four ele- ments of care’ (Tronto, 1993, p. 127).
The four phases of care are caring about, taking care of, caregiving and care receiving. Caring about involves ‘noting the existence of a need and making an assessment that this need should be met’ (Tronto, 1993, p. 106). So, in the nursing context one might see that a patient is uncomfortable and conclude that they have a need which should be met. Beyond the nursing context, one might be made aware of the plight of people in a disaster-struck country and come to the view that they have a need which must be met.
‘Taking care of’ involves ‘assuming some responsi- bility for the identified need and determining how to respond to it’ (Tronto, 1993, p. 106). So, to continue with the previous examples, the nurse in our previous example might work out which is the best way to respond to the patient in discomfort, similarly in the situation regarding responding to people in a disaster- struck country.
With regard to ‘care giving’, as might be expected Tronto describes this in terms of the ‘hands on’ work of responding to people’s needs. Thus, in our examples this would involve the nurse, e.g. making the patient comfortable, and, perhaps, by the person taking some action to help the people in the stricken country.
The last of these ‘phases’ of care ‘recognizes that the object of care will be affected by the care it receives’ (Tronto, 1993, p. 107). The examples Tronto provides of this are of a piano responding to having been retuned, a patient feeling better (e.g. more com- fortable) and a child feeling better after having been fed.
It seems reasonable to suppose that the choice of the term ‘phase’ by Tronto signals temporal ordering, such that the phases are gone through in sequence, though of course, as she makes plain, they overlap in part.
What then, of the four elements of care? The first of these is attentiveness, which involves the ‘recognition of a need and that there is a need that be cared about‘ (Tronto, 1993, p. 107). As she explains, fostering this attentiveness is important to try to ensure that people are not neglected – are cared for. Tronto also reminds us of the way in which being insufficiently attentive can be a moral failing. Thus suppose a nurse walks past a patient who looks to be in severe distress; the nurse simply fails to notice this in the face of the patient. That would be one example of the kind of moral failing – and perhaps professional failing also – to which Tronto is pointing and which brings out the significance of attentiveness in the moral domain.
The second element she identifies is that of ‘respon- sibility’ (Tronto, 1993, p. 107). I have discussed above the way in which this concept is used by Tronto to try to distinguish care-based from ‘obligation-based’ approaches to ethics. The part responsibility plays as one of these elements of care is slightly unclear to me. How
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