III. CONTEMPORARY ETHICS OF CARE

A major contemporary impetus to scholarly discussions of caring occurred with the 1982 publication of Carol Gilligan's In a Different Voice: Psychological Theory and Women's Development. Nursing theorists—and, to a lesser extent, physicians—were exploring moral dimensions of caring prior to the publication of Gilligan's work; but her book led, for the first time in the history of the idea of care, to widespread efforts to develop a systematic philosophical ethic of care beyond the world of healthcare practitioners.

Contemporary Elements of an Ethic of Care

In a Different Voice begins by contrasting the primary moral orientation of boys and men with the primary orientation of girls and women. Gilligan proposes that females and males tend to employ different reasoning strategies and apply different moral themes and concepts when formulating and resolving moral problems. According to Gilligan's analysis, females are more likely than males to perceive moral dilemmas primarily in terms of personal attachment versus detachment. From this perspective, which she dubs the care perspective , central concerns are to avoid deserting, hurting, alienating, isolating, or abandoning persons and to act in a manner that strengthens and protects attachments between persons. In this analysis, the moral universe of girls and women tends to be primarily "a world of relationships and psychological truths where an awareness of the connection between people gives rise to a recognition of responsibility for one another, a perception of the need for response" (p.30). For example, Amy, an eleven-year-old girl whom Gilligan interviews in her book, describes herself in terms of her connection with other people: "I think that the world has a lot of problems, and I think that everybody should try to help somebody else in some way …" (Gilligan, p. 34).

By contrast, Gilligan argues that the primary moral orientation of men and boys tends to focus on moral concerns related to inequality versus equality of individuals. Rather than emphasizing the importance of sustaining personal relationships, this approach emphasizes abstract ideals of fairness and rights, and requires abiding by impartial principles of justice, autonomy, reciprocity, and respect for persons. Viewed from this perspective, which Gilligan refers to as the justice perspective , moral dilemmas are defined by hierarchical values and impersonal conflicts of claims. The moral agent, like the judge, is called upon to "abstract the moral debate from the interpersonal situation, finding in the logic of fairness an objective way to decide who will win the dispute" (p. 32). To illustrate justice reasoning, Gilligan describes the moral reasoning of Jake, an eleven-year-old boy interviewed for her book. Asked how he would resolve a conflict between responsibility to himself and other people Jake answers, "You go about one-fourth to the others and three-fourths to yourself, " and adds that "the most important thing in your decision should be yourself, don't let yourself be guided totally by other people …" (p. 35–36). Gilligan concludes that Jake understands this moral dilemma as an abstract mathematical equation and perceives his responsibility for others as potentially interfering with his personal autonomy.

Gilligan, a developmental psychologist, argues that an ethic of care has been generally ignored in the past because girls and women have been excluded as subjects in the study of moral development. For example, accounts of moral maturation described by Lawrence Kohlberg (1981, 1984) and Jean Piaget were based entirely on studies and observations of boys and men. These male-based theories of moral psychology, when applied to girls and women, were interpreted as showing girls and women to be deficient in moral development. Gilligan identifies an ethic of care as a distinctive form of moral reasoning.

Implications for Ethics of Healthcare

The implications of Gilligan's analysis for contemporary bioethics are the subject of ongoing discussion. First, an ethic of care may lead to positive changes in bioethical education, including placing greater emphasis on healthcare providers' communication skills and emotional sensitivity, and on the effects that ethical issues have on relationships (Carse). To the extent that bioethicists with formal training in ethics are inclined to emphasize justice over care, it may be desirable to broaden their training to include an ethic of care (Self et al.).

In addition to producing changes in ethics education, a care orientation within bioethics arguably requires placing greater emphasis on beneficence as the healthcare provider's primary responsibility to the patient (Sharpe). Finally, an ethics emphasizing caring for others may produce substantive changes in the way we resolve moral problems. It may encourage resolutions of moral problems that give greater authority to family members in healthcare decision making (Hardwig, 1990, 1991; Jecker, 1990), or it may lead to paying greater attention to how various relationships are affected by moral decisions (Jecker, 1991).

One area within bioethics where an ethic of care has been studied in some detail is abortion. Gilligan found that women who face abortion decisions tend to frame moral issues in terms of a responsibility to care for and avoid hurting others. These women often base decisions about having an abortion on "a growing comprehension of the dynamics of social interaction … and a central insight, that self and others are interdependent" (p. 74). In other words, rather than conceptualizing abortion in terms of abstract values, such as life, or in terms of competing claims or rights, these women tend to see abortion as a problem of how best to care for and avoid harming the particular people and relationships affected by their choices. Considered in this light, the resolution of abortion requires taking stock of how any decision might affect not only the pregnant woman and fetus, but also the relationship between the pregnant woman and biological father, and relationships and persons within the wider family circle (Jecker, 1999). Arguably, an ethic of care illuminates the moral issues abortion raises better than an ethic of justice, because only an ethic of care portrays individuals as uniquely constituted by their connections to others (Gatens-Robinson).

In addition to these proposed changes, introducing a care orientation within bioethics may shed a negative light on more traditional forms of bioethical analysis (Carse). For example, Virginia Sharpe claims that a justice orientation has dominated bioethics in the past, and this has encouraged ethicists to treat provider–patient relationships as free exchanges between equals. She argues that this picture of the provider–patient relationship is seriously distorted. Rather than being equals in relationships with healthcare providers, patients typically experience diminished power and authority as a result of being physically and emotionally vulnerable and in need of the provider's help (Sharpe). Others charge that a justice orientation has traditionally prevailed within bioethics, resulting in too much focus on competition for power, status, and authority and too little focus on the human relationships at stake (Warren). For example, the autonomy–paternalism debate within bioethics concentrates on who has the authority to make treatment decisions. Similarly, when bioethicists emphasize impersonal ethical principles, such as autonomy, nonmaleficence, beneficence, and justice, the particular persons and relationships involved in ethical dilemmas can become incidental, rather than essential, to the crafting of moral responses.

Feminist versus Feminine Ethics

Gilligan's ongoing effort (Gilligan et al., 1988; Gilligan et al., 1989; Brown and Gilligan) to characterize the moral reasoning of girls and women in terms of care has occurred in tandem with important developments in feminist ethics. It is useful, however, to distinguish between the care ethic that Gilligan describes, which has been called a feminine ethic, and the development of feminist ethics. According to Susan Sherwin, the primary concern of feminine ethics is to describe the moral experiences and intuitions of women, pointing out how traditional approaches have neglected to include women's perspectives.

In addition to Carol Gilligan, both Nel Noddings and Sara Ruddick have made important contributions to feminine ethics. Whereas Gilligan emphasizes the unique form of moral reasoning that caring engenders, Noddings focuses on caring as a practical activity, stressing the interaction that occurs between persons giving and receiving care. From this perspective, she identifies two distinctive features of caring: engrossment and motivational shift. Engrossment refers to a receptive state in which the person caring is "receiving what is there as nearly as possible without assessment or evaluation"; motivational shift occurs when "my motive energy flows towards the other and perhaps … towards his ends" (Noddings, 1984, p. 33, 34). Critics of Noddings's approach raise the concern that her interpretation of caring may lead to exploitation (Houston) or complicity in the pursuit of evil ends (Card, 1990).

Unlike Gilligan and Noddings, Ruddick emphasizes maternal thinking, which she says develops out of the activity of assuming regular and substantial responsibility for small children. Although Ruddick acknowledges that the work of mothering falls under the more general category of caring labor, she argues that it cannot simply be combined with other forms of caring because each form of caring involves distinctive kinds of thinking arising from different activities (Ruddick). Ruddick delineates maternal thinking as a response to the small child's demands for preservation, growth, and acceptability. These demands elicit in the mothering person the responses of preservative love, fostering growth, conscientiousness, and educative control, which Ruddick identifies as the hallmarks of maternal thinking.

In contrast to feminine ethics, the primary concern of feminist ethics is to reject and end oppression against women. Susan Sherwin defines feminist ethics as "the name given to the various theories that help reveal the multiple, gender-specific patterns of harm that constitute women's oppression, " together with the "diverse political movement to eliminate all such forms of oppression" (p. 13). By oppression, Sherwin means "a pattern of hardship that is based on dominance of one group by members of another. The dominance involved … is rooted in features that distinguish one group from another" and requires "exaggerating these features to ensure the dominant group's supremacy" (p. 24). Feminism aims, in this interpretation, to show that the suffering of individual women is related because it springs from common sources of injustice. According to Rosemarie Tong, feminist ethics is typically far more concerned than feminine ethics with making political changes and eliminating oppressive imbalances of power (1993).

In many respects, however, feminine and feminist ethics are interrelated. The careful study of women's lives and moral reasoning that feminine ethics undertakes can contribute substantially to dismantling habits of thought and practice that enable women's oppression to continue. Both feminine and feminist ethics share the goal of adding women's voices and perspectives to various fields of scholarly inquiry. Finally, as Ruddick notes, feminist ethics can lend important support to the ideals that feminine ethics upholds. For example, feminist ethics can help to ensure "women's economic and psychological ability to engage in mothering without undue sacrifice of physical health and nonmaternal projects" (p. 236).

Objections to an Ethic of Care

Since the publication of In a Different Voice, the proposal to develop a feminine ethic of care has met with a variety of concerns and objections. One set of concerns is that a feminine ethic of care may unwittingly undermine feminism. These concerns stem, in part, from a belief that the qualities in girls and women that feminine ethics esteems have developed within the context of a sexist culture. Thus, some suspect that women's competency at caring for and serving others is an outgrowth of their subordinate status within modern societies (Sherwin; Moody-Adams), and worry that emphasizing caring as a virtuous feminine quality may simply serve to keep women on the down side of power relationships (Holmes). Susan Moller Okin, for example, cautions that women are often socialized from a very early age into strict gender roles, involving caring for and serving others. This socialization radically limits their future prospects by diminishing women's capacity to choose alternative life plans. We should therefore reject traditional socialization, because it seriously violates the equality of persons basic to liberalism. Others urge women to aspire to assertiveness, rather than caring, in order to challenge conventional images of women as concerned with serving and pleasing others (Card, 1991). Feminist critics also warn that caring cannot function as an ethic that is complete unto itself. Observing that caring can "be exploited in the service of immoral ends" (Card, 1990, p. 106), Card insists on the need to balance caring with justice and other values. Exclusive attention to caring can also lead to overlooking "the lack of care of women for women" and may preclude "the possibility of our looking at anything but love and friendship in women's emotional responses to one another" (Spellman, p. 216). Finally, excessive focus on caring at the expense of other values can blind us to the critical assessment of the object of caring. As Warren Thomas Reich noted in 2001, care by itself can be easily manipulated, and does not offer tools for analyzing the moral importance of what we care about.

In response, defenders of feminine ethics distinguish between distorted and undistorted forms of caring (Tong, 1998). Distortions of caring include the exploitation, abuse, or neglect of careers. As Tong notes, just because caring can become distorted does not suffice to show that an ethic of care is inherently distorted. Nor does it establish that "every woman's caring actions should be contemptuously dismissed as yet another instance of women's pathological masochism or passivity "; instead care should be preserved and celebrated in its undistorted form: "rescued from the patriarchal structures that would misuse or abuse it" (Tong, 1998, p. 171).

A second family of concerns about a feminine ethic of care relates to the belief that caring for others can lead to neglect of self. The phenomenon of burnout, for example, refers to the situation of parents, nurses, family caregivers, or other individuals who become utterly exhausted by the physical and emotional demands associated with giving care. Especially when care is conceived to be an ethic that is sufficient unto itself, the tendency may be to continue caring at any cost. Attention to other values, such as respect for the rights of the one caring, may be necessary in order to preserve the integrity of the caregiver: Arguing along these lines, Nancy Jecker notes that "if women are seen as having the same possibility men have to create a plan of life that places central importance [in activities other than caregiving] …, then a duty … [to care] can potentially stand in the way of what a woman wants to do" (2002, p. 128). The idea here is that individuals presumably prefer to protect, as much as possible, their freedom to choose whether or not to devote themselves to caring (2002). Others suggest that in order to care for others—which is an inherently limited ability—one must first be cared for by other individuals, by communities, and by oneself (Reich, 1991).

A third group of objections to developing a feminine ethic of care holds that the concept of care is not helpful at the social and institutional level. This group of objections may acknowledge that an ethic of care serves well within the limited sphere of personal ethics, but finds care unhelpful outside of this sphere. One form this objection takes is to argue that an ethic of care cannot be formulated in terms of the general rights and principles that are necessary for designing public policies. Proponents of a care ethic sometimes acknowledge this limitation. Thus, Noddings states, "to care is to act not by fixed rule but by affection and regard" (1984, p. 24). Similarly, Patricia Benner and Judith Wrubel maintain that caring is always specific and relational; hence, there exist no "context-free lists of advice" on how to care (p. 3). They reject the idea of formulating ethical theories or rules about caring on the grounds that general guides cannot "capture the embodied, relational, configurational, skillful, meaningful, and contextual human issues" that are central to an ethic of care (p. 6). Despite this view, there exist historically important examples of using the vocabulary of general rights and principles to formulate an ethic of care. For example, the UN's Universal Declaration of Human Rights identifies "motherhood and childhood" as "entitled to special care and assistance, " and that organization's Declaration of the Rights of the Child asserts general principles of caring for children, noting that children need "special safeguards and care" on the basis of their "physical and mental immaturity."

Another reason why care may be assumed unworkable at a social or institutional level is that historically, public and private spheres have been distinguished as separate moral domains (Elshtain). During the nineteenth century, for example, the doctrine of separate spheres held that the family constituted a private sphere in which a morality of love and self-sacrifice prevailed; this private domain was distinguished from the public life associated with business and politics, where impersonal norms and self-interested relationships reigned (Nicholson). To the extent that these historical attitudes continue to shape present thinking, they may lead to the mutual exclusivity of care-oriented and justice-oriented approaches. In response to this structural objection, some ethicists have argued that justice and care are compatible forms of moral reasoning (Jecker, 2002).

A final set of objections to a feminine ethic of care does not deny the importance of care, but rather argues that care is not properly interpreted as an ethic that expresses an exclusively feminine form of moral reasoning. Iddo Landau, for example, argues that the significant factors for preferring the use of care or justice ethics are, in fact, not masculinity or femininity, but factors such as education and economic class. Landau concludes that "Justice and care ethics should be seen as the ethics of certain economic classes and levels of education, not of men and women" (p. 57). Defenders of feminine ethics often meet this objection by claiming that their approach has been misunderstood. Thus advocates of feminine ethics may deny that care is an ethic that only women articulate, or an ethic that is valid only within the moral experience of women. According to Noddings, caring is an important ingredient within all human morality, and moral education should teach all people how and why to care. She concludes that "an ethical orientation that arises in female experience need not be confined to women"; to the contrary, "if only women adopt an ethic of caring the present conditions of women's oppression are indeed likely to be maintained" (1990, p. 171). Gilligan and Jane Attanucci also reject the idea that an ethic of care correlates strictly with gender, and instead report that most men and women can reason in accordance with both care and justice. Gilligan's research supports the more modest claim that care is gender-related. That is, although women and men can reason in terms of both care and justice, women are generally more likely to emphasize care while men generally emphasize justice. Thus she states that the so-called different voice she identifies is characterized "not by gender, but by theme, " and cautions that its association with gender "is not absolute" and is not a generalization about either sex (p. 2).

Caring and Contemporary Nursing

Within healthcare, attention to caring is perhaps most evident within nursing. Emphasizing caring as a central value within nursing often provides a basis for arguing that nursing requires its own description, possesses its own phenomena, and retains its own method for clarification of its own concepts and their meanings, relationships, and context (Jameton; Fry, 1989a, 1989b; Watson; Swanson; Reverby, 1987a, 1987b). For example, Jean Watson holds that nurses should reject the impersonal, objective models that she says currently dominate ethics and choose instead an ethic that emphasizes caring.

Those who invoke caring in developing a theory of nursing ethics often assign caring a privileged or foundational role. For example, Sarah Fry posits caring as "a foundational, rather than a derivative, value among persons" (1989b, p. 20–21). She argues that other ethical values, such as personhood and human dignity, are an outgrowth of nurses's caring activity. Similarly, Benner and Wrubel argue for the primacy of caring on the grounds that skillful technique and scientific knowledge do not suffice to establish ethical nursing in the absence of a basic level of caring and attachment.

Like Fry, Kristen Swanson regards caring as central to nursing ethics. According to her analysis, caring requires acting in a way that preserves human dignity, restores humanity, and avoids reducing persons to the moral status of objects. Specifically, caring requires:

1. knowing, or striving to understand an event as it has meaning in the life of the other;
2. being with, which means being emotionally present to the other;
3. doing for, defined as doing for the other as he or she would do for himself or herself if that were possible;
4. enabling, or facilitating the other's passage through life transitions and unfamiliar events; and
5. maintaining belief, which refers to sustaining faith in the other's capacity to get through an event or transition and to face a future of fulfillment.

Susan Reverby finds caring to be a central ethic throughout nursing's history. Tracing the history of nursing to its domestic roots during the colonial era, when nursing took place within the family, Reverby argues that caring for the sick was originally a duty rather than a freely chosen vocation for women. Reverby suggests that nurses today possess "some deep understandings of the limited promise of equality and autonomy in a healthcare system. In an often implicit way, such nurses recognize that those who claim the autonomy of rights often run the risk of rejecting altruism and caring itself" (1987a, p. 10).

Some have challenged the proposal to consider care as a foundational or unique concept for nursing ethics. Invoking a Nietzchean method of analysis, John Paley rejects the idea that caring is the core of nursing on the ground that it bears a striking resemblance to a slave morality and thus deteriorates into a celebration of weakness . He urges nursing to aspire instead to noble values, including competence in the management of recovery and rehabilitation. Other approaches do not reject a care ethic outright, but question the attempt to regard an ethic of care as unique to nursing. Robert M. Veach, for example, suggests that care is essential to human relationships generally. Others hold that care itself is still too broad a concept to demarcate what is unique about ethics in nursing, and instead identify nursing with maternal practice, a specific kind of caring activity (Newton; O'Brien). For example, Patricia O'Brien defends the importance of nursing's maternal function by noting that historically the source of nurses' prestige has been the manner in which nurses blend home and hospital. That is, nursing's strength has come from nurses' skill at the traditionally female tasks of feeding, bathing, cleaning, coaching, and cajoling those in one's care. Just as mothers make a home, it is female nurses who have been able to make a home of the hospital, to personalize an increasingly impersonal environment.

Critics of the maternal paradigm for nursing fault this approach as casting women in traditional and stifling roles. Historically, for example, nurses were socialized into the healthcare field to know their place and were relegated to the bottom of the pyramid and taught not to ask questions (Murphy). Casting nursing practice in terms of mothering potentially reverses progress made in the late 1970s when nurses began to see themselves as shared-decision makers rather than handmaidens to physicians (Stein et al.).

A further objection to identifying ethical ideals of nursing with ethical ideals of mothering holds that nurses's proper function is to serve as patients's advocates, rather than as patients' parents. Gerald Winslow, for example, argues that advocacy of patients' autonomy, rather than paternalistic promotion of patient benefit, should guide nursing ethics.

Caring and Contemporary Medicine

Whereas nursing is often associated with a caring function, doctoring has traditionally been associated with a curing function. However, the tendency to associate caring exclusively with nursing is misleading for a variety of reasons (Jecker and Self). First, both doctors and nurses are engaged in caring for patients. In addition, assigning caring activities to nurses and curing activities to doctors is misleading because certain meanings of curing are actually derived from caring. Thus, the Latin definition of cure comes from the word curare, meaning "care, heed, concern; to do one's busy care, to give one's care or attention to some piece of work; or to apply one's self diligently"(Oxford English Dictionary).

Although there has been less explicit attention to an ethic of care in medicine than in nursing, caring for patients represents a central component of ethics in medicine. Caring is inextricably linked to the physician's obligation to relieve suffering, a goal that stretches back to antiquity (Cassell, 1982).

There are several more specific ways in which an ethic of care becomes manifest in the practice of medicine. First, caring is manifest in the activity of healing the patient. Whereas curing disease typically requires the physician to understand and deal with a physical disease process, healing requires that the physician also respond to the patient's subjective experience of illness (Cassell, 1989). For example, healing a patient who is suffering from a serious infection requires not only administering antibiotics to kill bacteria but also addressing the patient's feelings, questions, and concerns about his or her medical situation. In cases of serious illness where cure is not possible, caring for the patient may become the primary part of healing. For example, when patients are terminally ill and imminently dying, physicians' primary duty may become providing palliative and comfort care. Under these circumstances, healing emphasizes touch and communication, psychological and emotional support, and responding to the patient's specific feelings and concerns, which may include fear, loss of control, dependency, and acceptance or denial of death and final separation from loved ones.

Caring is also evident in what Albert Jonsen calls the "Samaritan principle : the duty to care for the needy sick, whether friend or enemy, even at cost to oneself" (p. 39). The tradition of Samaritanism dates to the early Christian era and the parable of the Good Samaritan described in the Gospel according to Luke; it persists during the modern, secular era as a central ethic for medicine. Jonsen argues that although the original Christian parable of the Samaritan refers to giving aid to a particular individual, the ethical tradition of Samaritanism within medicine bears relevance to entire groups of patients. So understood, Samaritanism underlies the physician's broader social duty to care for indigent persons. In contrast to the past, when physicians provided charity care for indigent persons without financial remuneration, universal health insurance is the norm in most developed countries. Therefore, in contemporary times physicians are generally compensated for their services through a private or government health insurance mechanism. In the United States, however, large numbers of patients continue to lack health insurance. A principle of Samaritanism continues to be evident in the legal and ethical requirement thatU.S. physicians provide emergency treatment to any patient regardless of the patient's ability to pay for care. A stronger Samaritan ethic, mandating access to all forms of basic healthcare, would require, in the United States, successful implementation of healthcare reform.

A third way in which caring is manifest in the ethics of medicine is through the healing relationship of doctor and patient. Edmund Pellegrino and David Thomasma regard this relationship as one of inherent inequality because the patient is vulnerable, ill, and in need of the physician's skill. In light of the patient's diminished power, Pellegrino and Thomasma argue that the physician incurs a duty of beneficence, a duty requiring the physician to respond to the patient's needs and promote the patient's good. Other ethical values in medicine can presumably be derived from the physician's primary duty of beneficence. For example, according to Pellegrino and Thomasma, a duty to enhance patients' autonomy is based on the duty to benefit patients.

Some, Sharpe for example, have sought to identify the principle of beneficence that Pellegrino and Thomasma delineate with an ethic of care. However, beneficence and care differ in crucial respects. Whereas a principle of beneficence identifies promoting the patient's good as a requirement for right action, an ethic of care is a type of virtue ethic that is basically concerned about the affective orientation and moral commitment—that is, the concern—of the one who cares. For example, a physician may perform actions that promote a patient's good, and thus meet the requirement of beneficence, without caring about or feeling any commitment toward the patient. If this analysis is correct, then actions that fulfill the principle of beneficence do not necessarily fulfill standards associated with an ethic of care. An ethic of care suggests both a feeling response directed to the object of care and a commitment to ensuring that things go well for that person.

Despite the integral role that an ethic of caring plays in medicine, contemporary physicians sometimes neglect to offer adequate palliative and comfort measures to patients. This may stem from a failure to teach and nurture empathy in medical education (Spiro et al.) and from financial incentives that discourage spending time at patients's bedsides and getting to know patients as persons. In addition, physicians may overlook caring for patients when conflicts exist about the use of futile treatments (Schneiderman et al.). For example, members of the healthcare team may become distracted debating the appropriateness of high-technology interventions and neglect to care for patients's spiritual and emotional needs.

Conclusion

Although the development of theories of an ethic of care for healthcare is new, the idea of care has long presented a moral standard or ideal for healthcare. Although caring has been an abiding concern within nursing practice, within medicine care has sometimes been overshadowed by other ethical values and goals. The emergence of feminine ethics can play an important role in reemphasizing the value and importance of caring within medicine. However, the close association of care with gender and with the feminine voice may hinder efforts to develop a broader human understanding of care, such as the understanding of care that emerged earlier in human history.

nancy s. jecker

warren thomas reich (1995)

revised by nancy s. jecker

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

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