II. HISTORICAL DIMENSIONS OF AN ETHIC OF CARE IN HEALTHCARE

In the context of healthcare, the idea of care has two principal meanings: (1) taking care of the sick person, which emphasizes the delivery of technical care; and (2) caring for or caring about the sick person, which suggests a virtue of devotion or concern for the other as a person. At times these two aspects of care have been united; at other times they are in conflict.

Taking Care of: Competent, Technical Care

When speaking of the medical aspects of "taking care of" the patient, one often uses the language of taking good care, or receiving appropriate care. This practical vision of care can be viewed historically from the perspectives of medical competence and technical excellence. The Greek demigod Asklepios, because of his reputation for competence, became the "patron of human healers" (Jonsen). The virtue that motivated the physician of classical Greece was philotechnia, or love of the art (May, 1983; Laín Entralgo). In the Greek tradition, "the love of technical skill included not only an appreciation of the good which the application of that skill might achieve but also a kind of natural piety that recognized the limits of the art" (May, 1983, pp. 92–93). The ethic of competent care can also be called a Hippocratic ethic, after Hippocrates (c. 460–378 b.c.e.), the "father of medicine." One phrase in the Hippocratic oath—"I will act for the benefit of my patient according to my ability and judgment"—implies the imperative of the competent practice of the art of medicine (Jonsen). Under these historical influences, competence, "in the sense of a disciplined understanding of the science and skilled manipulation of the art [of medicine], " was regarded as the first virtue of medical care at least through the seventeenth century (Jonsen, p. 22).

In modern times, competence has become the essential and comprehensive virtue of medicine; medical practice and education came to emphasize ever-more-complete scientific knowledge and ever-more-competent clinical performance. This demanding standard of competence in turn fueled a drive toward biomedical excellence and deepened the sense of meaning and pleasure gained from practicing the art of medicine (May, 1983; Jonsen).

At the turn of the twentieth century, as medical competence focused more and more intently on the principles of pathophysiology and factual diagnostics, medical "care" came to be defined by objective data. Clinical and laboratory efforts to comprehend, apply, and evaluate medical data led physicians increasingly to divorce the disease from the patient, thus marginalizing personal care. The desire for liberation from the sometimes oppressive consequences of emotional involvement in "caring for" the person who is in critical condition may have contributed to this trend. As increased technical expertise raised expectations of what "taking care" should mean, legal and ethical requirements of "due care" spelled out the criteria for medical care, prompting clinicians to focus even more on the technical ideal of competence in "taking care of the sick" (Annas).

By the 1920s, competent care was becoming the moral meaning of "taking care of" the patient. Richard C. Cabot (1868–1939), a renowned professor at Harvard Medical School, articulated and championed this new ethic of competence. The humanistic virtue of "caring for" the patient was quickly pushed to the periphery of medicine, for that sort of care was viewed as bearing no apparent relation to the highly esteemed "hard data." This narrowing of the notion of care placed medical ethics in crisis (Jonsen).

Caring for the Sick Person

While "taking care of the patient" in competence had been pushing "caring for" the patient to the periphery of medical concerns, "caring for" the patient received a major impetus at Harvard during the 1920s. This section will consider what altruistic terms and virtues "caring for" replaced, why they had lost their meaning, an account of the onset of the term caring for, and its meaning in healthcare prior to 1982.

The moral term caring for was turned to at a time when the altruistic virtues that had shaped the care of the sick for centuries had lost much of their luster, particularly terms like hospitality, philanthropy, charity, love, and sympathy.

For example, hospitality, which meant the friendly and cordial taking in of strangers or travelers, had enormous influence as an altruistic virtue for healthcare; it was a model in rabbinic Judaism, early Christianity, and Islam (Exod. 23:9). Christianity had transformed hospitality from a private into a public virtue of mercy and beneficence that was often directed to the sick stranger (Bonet-Maury). Hospitality prompted establishment of travelers' inns, which evolved into hospices where healthcare was sometimes provided, and eventually to hospitals, especially in the Byzantine East but also eventually in the Latin West (Miller). But by the 1920s, this religious term had lost its force; even Christians no longer spoke of hospitality as a major public virtue motivating healthcare.

Philanthropy had, for centuries, been a dominant altruistic motive for "caring for" the sick in most religious traditions, but it has virtually disappeared from the moral sphere of healthcare. The ideal of philanthropy (from the Greek philanthropos, meaning humane or benevolent) encouraged a love of humankind that expressed itself in concrete deeds of service to others. Philanthropy, associated with the Christian ideal of charity, made it possible for the sick person to assume a preferential position in society (Sigerist) and motivated the establishment of hospitals starting in the fourth century in the East, until modern times in the West. The ideal of philanthropy also appeared strongly in the first code of medical ethics, adopted by the American Medical Association in 1847. But by the 1920s, professional philanthropy, from which modern professionals had derived much of their authority and prestige, had lost much of its respect, and the significance of the word philanthropy had been reduced to its meaning of private (and to some extent, public) support of the arts, education, and research (May, 1983, 1986).

Sympathy and compassion have exerted a strong public influence on caring for the sick in times past, in particular by motivating the sensitivities of individual medical practitioners. Codes and oaths have exhorted health practitioners throughout the ages to care for the sick out of motives of compassion and sympathy. John Gregory (1724–1773) spoke of the sensibility of heart that makes us feel for the sick and arouses in us the desire to relieve their distresses. Use of the word sympathy to motivate personalized medical care appeared commonly right up to the 1920s and beyond. But the word sympathy lost its effectiveness as it often came to be regarded as the condescending manifestation of pity; the word compassion was looked on with some disfavor as it came to suggest too much identification with the suffering person.

In addition, there is an overarching reason why the previous caring virtues were discounted, leaving room for the new, secular term of care. In criticizing ecclesiastical institutions in the eighteenth century, Enlightenment thinkers denounced charity for the sick and philanthropic hospitals because these activities were tainted by the essentially self-centered gifts and legacies of pious people who sought to atone for their sins by acts of charity in support of the hospitals. Eighteenth-century rationalists emphasized that the poorly organized philanthropic hospitals of Christian Europe did little to help the sick get well; and some Enlightenment thinkers blamed the very concept of Christian charity for these abuses. Furthermore, Christian charity was regarded as too closely linked to dead traditions and blind superstitions to have a close relationship with science (Locke). The attempt by some philosophers in the eighteenth, nineteenth, and twentieth centuries to base an altruistic care of the sick on a secular notion of sympathy was, in part, a result of these developments.

By the 1920s, the secular term care had begun to replace the earlier altruistic terminology. By this time, the history of the idea of care had progressed to the point that the term was coming to be known for its moral implications. In addition, care had special appeal as a virtue for healthcare because the same word had—for centuries and in a variety of languages— been the descriptive term for "taking care of" sick people. It should be no surprise, then, that for a number of decades prior to 1982—when the idea of care began capturing widespread contemporary attention—there appeared a small body of literature in the clinical ethics of physicians and nurses as well as in religious medical ethics that focused attention on the moral meaning and practice of care, as well as on an ethic of care.

"Caring for" in Clinical Medical Ethics, 1920–1982

In championing the fast-developing technical art of medicine, Richard C. Cabot acknowledged and seemed to acquiesce in the fact that doctors and nurses were not caring for the whole patient: Their attention was "too strongly concentrated" on the difficult tasks of diagnosis and treatment, and "there is not enough attention left to go round" (Cabot, p.16). He was certainly in favor of manifesting courtesy and patience with sick people; but under some conditions, he said, it is not advisable for the physician to care for anything but the patient's body; and when care for the whole person is desirable, others—medical students, social workers, and even ministerial students—can suitably offer that kind of care (Cabot). To carry out his purpose of designating surrogates who would "care for" the patient, Cabot was instrumental in establishing the professions of medical social work and clinical pastoral care.

The following year, Francis Peabody, a physician-professor colleague of Cabot at Harvard, offered the opposite point of view. "Caring for" the patient is essential to the practice of medicine, he argued; physicians must engage in this sort of care in order to achieve the goals inherent in medicine. His 1927 essay "The Care of the Patient" is one of the foundation stones of an ethic of care in twentieth-century medicine in the United States (Peabody).

Peabody acknowledged that the "enormous mass of scientific material" to which a young doctor must be exposed, the depersonalized aspects of modern hospital practice, and physicians' bias toward organic disease could jeopardize the personal aspects of the art of medicine. To remedy these problems, he urged the physician to form and be attentive to a personal relationship with the patient and with the patient's "environmental background." The treatment of a disease, which may be impersonal, "takes its proper place in the larger problem of the care of the patient"(p. 396), which "must be completely personal" (p. 389). His oft-quoted principle was: "One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient" (p. 401).

The physician must be attentive to particular circumstances of the patient, "not from the abstract point of view of the treatment of the disease, but from the concrete point of view of the care of the individual" (p. 398). Peabody was clearly attempting to exonerate the usefulness—indeed, the necessity—of care in the practice of good clinical medicine when he argued that neglect of careful attention to the true situation of the whole patient, including functional disorder, jeopardizes diagnosis, treatment, and effectiveness of care. Furthermore, the mere caring effort in the relationship with the patient, aside from drugs or other treatments, can help patients get well. This sort of care requires attentiveness and alertness to what kind of a person the patient is; sympathy for the patient's total situation; friendliness that elicits trust; and a consideration expressed in "little incidental" actions that assure the patient's comfort—which may require that the physician learn much from the nurse regarding practical care and comfort of the patient.

Following Peabody's clarion call for care in 1927, several physicians, writing in the 1960s and 1970s, advocated a caring perspective in professional attitudes, practices, and moral analysis in medicine. The starting point that convinced these writers of the need for "caring for" was the depersonalization of medical care in hospitals. Clinical care oriented to the disease in the body leads caretakers to allow technical considerations to dominate, avoid death at any cost, and ignore patients' preferences; this produces indignities for patients and suffering for caregivers (Benfield).

The concept of caring is defined in the literature of the 1960s and 1970s as implying a broader concern for the whole patient, or for the quality of the patient's life, rather than just for the patient's disease (Menninger; Benfield). Caring involves sympathy with the patient, which entails entering into or sharing the feelings of the patient. To prevent loss of objectivity and perspective, "compassionate detachment" (Blumgart, p. 451) is recommended, which is "to sense the patient's experience empathically without becoming so involved sympathetically that the physician's rational and effective clinical judgment is impaired by emotional involvement" (Menninger, p. 837).

Caring for the patient embraces both the science and art of medicine; both are oriented to the patient, and both should meet in the individual physician (Blumgart). A caring solicitude for the individual patient is integral and essential in the practice of clinical medicine (Tisdale); failure to practice caring medicine leads to incomplete or inaccurate diagnosis and ineffective treatment (Blumgart). On the other hand, patients manifest care-seeking behavior (Tisdale). Receiving the sought-for care can be crucial for the patient's "adaptation to various maladjustments, including illness" (Menninger, p. 836). The role of the physician and other healthcare providers in our society is one of a surrogate caregiver, who has the power to give attention to the ill and excuse them from the performance of everyday duties (Menninger).

There are several obstacles to caring in medicine. The demands of the scientific and technological aspects of medicine, combined with physicians' fascination with disease, achieve great progress for humankind but tend to block out compassionate attention to suffering and the particular needs of the ill individual who has the disease. In addition, patients and families are reluctant to communicate their feelings with health professionals, who are too busy monitoring the patient's physical condition to listen. Other factors that obstruct person-oriented caring are (1) lack of teamwork among healthcare providers, coupled with over-emphasis on the physician's hierarchical authority; (2) caregivers' feelings of inadequacy due to lack of training in caring for critically ill or dying patients and their families; and (3) time pressures on health professionals (Blumgart; Benfield).

Acts of caring, some of which counteract the obstacles to caring, include: listening to patients with personal attentiveness, particularly as a history-taking technique that enables patients to relate their experiences in terms of their own values and concerns (Tisdale; Blumgart); being attentive to both the physical and the emotional components of illness (even though medical education and practice tend to focus on the physical—in fact, all medicine is psychosomatic, since the emotional and bodily factors always interact in every disease) (Blumgart; Menninger); and offering maximum understanding, freedom, and support to the individual patient (Tisdale).

Caring is also expressed through acting as companion to a bereaved family; solicitous communication regarding the nature of the illness and its expected course; sharing the patient's and family's responsibility and agony of deciding whether to continue care; relieving the patient of suffering from pointless dehumanizing treatment; and caring for caretakers who suffer the stress of the combined roles of technical caregiver and concerned caregiver (Benfield).

William Tisdale, writing in 1979, contended that modern medical ethics, with its concern for "the neon problems" of high controversy, is ill-adapted to account for an ethic of care. Because clinical caring pertains to the usual and the commonplace in medicine, it is more difficult to isolate and analyze. William Tisdale appealed for an inquiry into the unresolved and even the unrecognized problems inherent in basic clinical care and the problems inherent in care that are more demanding from an ethical perspective than the usual moral quandaries in medicine. In formal ethical terms, Tisdale saw clinical caring as characterized by the ideals of love and charity and as a form of duty beneficence, a duty to benefit others apart from special relationships and responsibilities. Making certain that expected benefits of a particular procedure outweigh the definite risks is a characteristic of caring for one's patients.

In the highly influential book published in 1970, Patient as Person, Paul Ramsey linked care with "covenant fidelity, " which he saw as the appropriate norm for the relationship between physician and patient. Covenant fidelity always requires care, which is directed to the person of the patient. But at the end of life, when attempts to cure are no longer appropriate, one must always care even if one only cares—through keeping company and offering comfort— while permissibly withdrawing medical care.

Caring for the sick, the wounded, and the troubled has been characterized through the centuries by altruistic motives and virtues. By the 1920s, an interest had arisen in the virtue of care as the basic moral orientation to healthcare, based in feelings for the other. Practitioners felt that care could provide the grounding for the moral practice of healthcare and for mitigating some of the excesses of medical technique. Still, very little by way of a formal ethic had arisen.

Caring in Nursing Theory, Philosophy, and Ethics

It required the intellectual and moral energy of feminist perspectives on care in the 1980s to establish a noteworthy movement promoting an ethic of care that reached deep into the field of bioethics.

Nursing theorists, educators, and philosophers explored and applied a more extensive theory and ethic of care prior to 1982 than any other single group had. Their contributions differed considerably from those of physician-writers: The nursing theorists paid much more attention to the meaning and theories of nursing, examined the structures and functions of care, turned occasionally to philosophers who had explained the meaning of care (such as Martin Heidegger and Milton Mayeroff), developed the implications of care for nursing practices and skills, considered the status of caregivers, showed an interest in the historical links between nursing and maternal care, and proposed educational improvements to foster professional care.

The strongest impetus for an examination of the role of caring in nursing came from Madeleine Leininger, who has organized national conferences on caring and published on the topic (1981). Leininger was one of the pioneers who fostered the idea that caring is the essence of nursing and the unique focus of the profession. Leah Curtin went a step further when she claimed that the distinctiveness of nursing cannot be located in functions, but in "the moral art of nursing, " in its primary moral conviction, by virtue of which nurses "are committed to care for, as well as to the care of, other human beings" (p. 26).

Nursing theorists offer a variety of definitions of care: for example, the explanation that caring in nursing is a process in which one shows "compassionate concern for the individual" (Gaut, in Leininger, 1981, p. 18). Leininger suggests this definition of professional nursing care: "those cognitively learned humanistic and scientific modes of helping or enabling an individual, family, or community to receive personalized services through specific culturally defined or ascribed modes of caring processes, techniques, and patterns to improve or maintain a favorably healthy condition for life or death" (1981, p. 9). This definition includes concepts of compassion, concern, nurturance, stress alleviation, comfort, and protection.

The precise historical origins of a concern for caring in nursing are unclear, but a number of authors trace them to the writings of Florence Nightingale. However, nurse theorists have relied not so much on a history of care in nursing as on the writings of social scientists and existentialists such as Buber, Erikson, and Rogers (Gaut, in Leininger, 1981).

Why did nursing theorists turn so strongly to the idea of care in the 1970s? Marilyn Ray explains that as nursing became increasingly technological, bureaucratic, managerial, and supervisory, nurses began experiencing a struggle relative to their central focus as a "direct caring profession" (Ray, in Leininger, 1981, p. 28). Barbara Carper (1979) answers the question by mentioning two factors that have had the effect of eroding care in health generally, not just in the experience of nurses: depersonalization of healthcare due to the fragmentation of specialized treatment, the subdivision of tasks, and highly institutionalized bureaucracy; and technological progress and technical expertise, which she saw as having the potential of overshadowing individuals, "reducing them to objects or abstractions" (p. 13). Within such a system, even when competent, scientifically based care is delivered, it "is often perceived by the client as lacking the 'personally experienced feeling of being cared for'" (p. 13, quoting Menninger, p. 837). This depersonalization of the individual entails the devaluing and loss of identity of the individual. She sees a compelling metaphor for the relationship of technology to care in the novel in which Dr. Frankenstein created a monster. Frankenstein's tragedy was not due to his scientific triumph over nature, but "his failure to care for what he had created. He was unable to recognize or experience the humanness of another's self" (Carper, p. 13).

Finally, even prior to the emergence of an ethic of care in other disciplines, nurses were already applying the idea of care both to nursing practice and to nursing ethics. For example, Carper argued that caring is the most essential ingredient in the curative process, because caring acts and decisions "make the crucial difference in effective curing consequences" (Carper, p. 14, quoting Leininger, 1977, p.2). Anne J. Davis stimulated reflection on the relationship between caring and ethical principles in the context of taking care of the dying. She contrasted the compassionate meaning of care (to undergo with, to share solidarity with) with the technical terms nursing care or medical care. She argued that situations of serious illness and dying call for putting aside the instrumental meaning of caring and instead manifesting "the most demanding and deeply human aspect of caring: the expressive art of being fully present to another person" (p. 1). A caring attitude would incline the nurse not to turn away from the stranger's world of suffering, but to appreciate the other person's independent existence and enter into and share his or her pain as much as possible. Caring for the sufferer is an ethical obligation inherent in the health professional's role. But caring transcends role obligations: It acknowledges the vulnerable humanness of the other and reinforces the caring of the one who cares. Ethical principles are not at variance with care: They provide specific judgments in the context of caring for another person. A caring disposition inclines caregivers to respect the patient as an autonomous agent and to recognize the patient's considered value judgments, even if they go contrary to what the clinician expects.

The foregoing presents a few indications of the pioneering work in nursing care theory and ethics in the 1970s. As the following entry indicates, the ethics of nursing care expanded considerably after the notion of care came to be more widely acknowledged through the writings of women social scientists.

warren thomas reich (1995)

bibliography revised

SEE ALSO: Alternative Therapies; Beneficence; Chronic Illness and Chronic Care; Compassionate Love; Emotions; Feminism; Healing; Human Dignity; Long-Term Care; Medicine, Art of; Nursing Ethics; Obligation and Supererogation; Paternalism; Professional-Patient Relationship; Women, Historical and Cross-Cultural Perspectives; and other Care subentries

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