Care Ethics and Social Structures in Medicine

Ruth E. Groenhout

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429816581
• Edition: 1
• Topic: Medicine
• Subtopic: Clinical Medicine

This book examines the central structures in medicine—medical knowledge, economics, technological innovation, and medical authority—from the perspective of an ethics of care. The author analyzes each of these structures in detail before considering the challenges they present to end of life care. The perspective of an ethics of care allows for a careful focus on how these structures affect the capacity of the health care system to provide the care patients need, on the impact they have on the relationships between patients and care-givers, and on how they affect the care-givers in terms of their own sense of identity and capacity for care. This book offers one of the first focused discussions of an ethics of care across a wide range of social issues and structures in contemporary medicine. It will be of keen interest to advanced students and scholars in bioethics and health care ethics who are interested in these important issues.

1 Care Ethics and the Practice of Medicine

The problems facing health care in the contemporary world are massive. The costs of health care continue to rise at astonishing rates, technological advances contribute to those spiraling rates, and caregivers find themselves increasingly working in a setting where patient care is compromised, burnout is rampant, and bureaucratic oversight creates serious inefficiencies. But addressing any of these problems on its own seems almost impossible because of the interwoven factors that structure health care in the modern world. Between the complex interactions between insurers, caregivers, patients, and politicians, and the added complexities of clinical research, hospital bureaucracies, alternative medicine, and legal oversight, there are no simple answers to the question of how health care could be reformed.

Nor can this book offer any easy solutions, but it can bring some clarity to the various issues that contribute to the complexity of contemporary health care. If we begin with a focus on the specific issue of care—the care that is provided by doctors, nurses, and other professionals, and supported by a wide range of institutional structures, from insurance companies to hospital administrators, from researchers to lawyers to politicians—and if we keep our focus on what does and does not support the provision of care itself, we will find that the lack of easy answers does not rule out the possibility of thinking in new ways about the provision of health care. So this book examines the big, over-arching structures of health care: knowledge, economics, authority, and technology, and examines them using the perspective of an ethics of care to think through how some of the problematic aspects of those structures might be addressed.

This book brings the resources of an ethics of care to an analysis of central structures in medicine: structures of knowledge, economics, authority, and technology, examining the realm of contemporary medicine through the lens of a care ethics account of relationships and how they function.

This first chapter begins with a brief account of care ethics, its history, and current development. After this very rough sketch, I offer a more specific development of the particular features of an ethics of care relevant to my analysis in this book, identifying the specific aspects of an ethics of care I will rely on in my analysis. The chapter then turns to the question of what I am calling ‘social structures in medicine.’ The structures I want to identify by this phrase are structures that aren’t determined (solely) by intentional policy decisions or identified in consent forms. Instead, what I am interested in are the background structures that function in contemporary medicine—structures that shape the practice of medicine profoundly, but which are not best addressed in terms of individual choice. Some of these practices have changed rather radically in recent decades (the shift from a clinical judgment model to an evidence-based model of medicine, for example). Others change only incrementally (the authority structures in medicine remain largely unchanged, in spite of numerous attempts to move to medical team models and shared decision-making). In the last section of this chapter, I discuss what I am calling social structures in a bit more detail, as well as explain why I have chosen to examine precisely these ones, and some general notes about what an ethics of care perspective brings to an analysis of such structures.

Care Ethics: A Brief Introduction

The ethics of care has its earliest beginnings in the writing of various feminist theorists starting in the 1980s. The term ‘ethics of care’ itself was coined by Carol Gilligan in her book In a Different Voice, a book in which she argued that men and women frequently spoke in ‘different voices’ in ethics, men tending to use a voice of justice, while women used a voice of care (Gilligan, 1982). By these two terms, Gilligan separated out concerns about rights, principles, boundaries, and protection of autonomy (masculine ethics, using the language of justice) from concerns about relationships, care, emotional bonds, and protection of connections (feminine ethics, using the language of care).

Women’s Voices and Practices of Care

Gilligan’s book touched off a wide-ranging discussion of ethics, gender, social policy and research methodology that went on for a good two decades. Many theorists found her research problematic (Brabeck, 1993), others rejected the dichotomy between care and justice (Friedman, 1993), and there was intense criticism of her linkage between a particular ethical voice and women (Card, 1995). But she did provide a term for something that clearly resonated with many feminist thinkers. Nel Noddings, in particular, wrote Caring: A Feminine Approach to Ethics and Moral Education, in which she argued that traditional ethical theory has consistently excluded women’s voices and concerns, and that this exclusion has resulted in a lack of attention to aspects of ethics that are particularly important in many women’s lives, namely: emotional connections, relationships, and the provision of care to the vulnerable and needy (Noddings, 1984).

Like Gilligan’s work, Noddings’ work proved controversial, with critics charging her with naiveté (Koehn, 1998) and with producing an ethics that entrenched patterns of exploitation of women (MacKinnon, 1987). Regardless of the controversy, however, Noddings’ work was important for its willingness to speak from a perspective that took the sorts of jobs many women have performed throughout time and across many regions, and examined the way that doing this work might shape one’s understanding of ethics.

As care ethics developed, this focus on how practices shape both an individual’s capacity to care and their capacity for moral reasoning became a central part of care theory. Sara Ruddick, for example, examined the way that practices of mothering develop epistemic virtues that are crucial for human life. (Mothering, on Ruddick’s account, is a practice that both men and women could engage in, but it has historically been a set of tasks relegated to women.) Among these epistemic virtues are attentiveness, knowledge of basic features of human flourishing, and (more controversially) pacifism (Ruddick, 1989). The analysis of practices and their relevance to care ethics has been central for many subsequent thinkers (Myers, 2013; Tronto, 2012; Kittay, 1999) and provides the focus on the sorts of knowledge and emotional habituation that develop with the performance of particular sorts of practices and social roles that I will rely on in this book. Just as mothering can develop skills, habits, and epistemic virtues, medical practices can develop ethical skills and habits, as well as epistemic virtues, that are crucial to the provision of care. But improperly structured practices can do the opposite, and can force practitioners to cease caring and to become emotionally distant and prone to ignore ethically relevant aspects of a situation.

The combination of Gilligan’s language of a feminine voice, Noddings’ focus on women’s experience, and Ruddick’s emphasis on mothering meant that early discussions of an ethics of care took place largely under the rubric of feminist ethics and women’s issues. While not all theorists who work with an ethics of care are women (this acknowledgment will come as a relief to Lawrence Blum, Michael Slote, and Maurice Hamington, I imagine), all take women’s experiences seriously because of the centrality of what is often called care work to both women’s experiences and the development of care ethics. Michael Slote goes so far as to consider the possibility that women are naturally more ethically gifted than men (Slote, 2007, p. 71). The more common position in care ethics has been that the social roles women tend to play generate the sort of caring concern and attentiveness that ground ethical responsiveness more generally (Noddings, 1984, 1989; Held, 1993, 2006; Hamington, 2004). Because particular social roles and types of work provide training in care work, then, and care work provides the context for an analysis of care more generally, care work and related practices have been a central focus of care ethics.

Care work, loosely defined, is the work done to provide care for others, particularly the care that is needed to take care of bodily needs, but also the work needed to develop and sustain basic capabilities in the other (Tronto, 1994; Engster, 2007). It includes such practices as mothering (or parenting—there is some debate over what the better term is), elder care, daily activities such as housekeeping, cleaning, and cooking, and a wide range of other activities. All of these provide for central needs in human life, all require repetition and continuous re-doing of the work, and all tend to receive very low payment, if those performing them are paid at all. The specific sort of care this book focuses on is health care: the care work that attends to health needs of individuals and populations, provided by professionals (for the most part) in systems organized socially to provide medical care and health support services to a population. This socially structured provision of care is a central concept in nursing theory (Watson, 2012; Boykin and Schoenhofer, 1993; Bishop and Scudder, 1991). It has been less prominent as a theoretical component of medical ethics, though it is a vital part of medical practice, as indicated by the way that medical practice is regularly referred to as medical care, and those who provide it as caregivers.

Care work requires a set of habits and practices that are central, care theorists have argued, for the ethical life. Attentiveness (for example, the capacity to see that a toddler is uncomfortable because he needs to go to the bathroom), the willingness to notice that a sticky counter needs to be wiped off, or the recognition that an elderly client is suffering from an unusual level of dementia, straddles the boundaries of epistemology and ethics because it is both a matter of knowledge and a matter of will. One has to care about another to be fully attentive, but one also has to process the information that comes from caring. In addition to attentiveness and understanding, care work also requires imaginative development, as noted by Maurice Hamington and Rita Manning (Hamington, 2004; Manning, 1992). The development of an embodied imaginative awareness of another’s situation, in particular, is a crucial part of care in general, and a vital part of the caring work that goes on in the medical field (Vosman, 2017; Halpern, 2001). These epistemological capacities and skills cannot be developed simply by reflection. They are, as Hamington emphasizes, embodied skills, developed through engagement in specific practices of care. The capacity to engage in them is damaged when the social structures one inhabits trains one to ignore or become insensitive to another’s needs or suffering, and can be virtually destroyed when one engages regularly in practices that inflict damage or harm on others. Practices of care generate skills that one needs time to acquire, and performing caring work well requires practice and imaginative engagement.

Because of the ways that caring practices shape a person’s character and generate epistemological capacities for recognizing what care requires, engaging in care practices shapes one’s character and perspective on issues in important ways. Among them, as Sarah Ruddick and Eva Feder Kittay have noted, is the capacity to see connections among people—Ruddick argues that mothering can be the basis for a politics of peace, while Kittay argues that seeing all people as ‘some mother’s child’ fundamentally changes one’s attitude toward strangers and others (Ruddick, 1989; Kittay, 1999). In both cases, the connections are not deterministic (mothers can support war efforts, and mothers can also be pretty brutal toward other people’s children), but connections nonetheless exist. One might note in this context the extent to which women have been portrayed as insufficiently ‘principled’ to be truly ethical precisely because they do tend to care about the lives and suffering of other people’s children. As Kant puts it: “I hardly believe that the fair sex is capable of principles… . But in place of it Providence has put in their breast kind and benevolent sensations” (quoted in Mahowald, 1994, p. 105). Far nobler the masculine willingness to kill than the feminine proclivity to pardon, in his view.

Rejecting the simplistic gender essentialism that prompts the Kantian claim, we can still note that there are clear correlations between providing care and being capable of seeing and responding to the specific needs of who and what are cared for. Caregivers tend to have a fairly realistic sense of the nature of those cared for, what they need to flourish, and what nuances of behavior indicate problems. Whether we are considering plants, dogs, patients with Alzheimer’s, or second graders, those who work with them day in and day out are most likely to have practical wisdom about the best way to meet their needs and help them flourish; they are also more likely to pursue other policies that protect the standing of those they care for. Elementary teachers vote for the political party they think will preserve money for education, gardeners tend to support land preservation policies, and so on. There is, of course, an element of circularity in this account—providing care for the vulnerable makes one particularly capable of seeing the need for care, and of seeing what care requires—but the circularity is not vicious, but rather akin to Aristotle’s notion that the person who becomes virtuous knows more about what virtue requires than others. The development of practical wisdom requires practice.

Health care work, however, generally requires more than just practice in caregiving. Health care is a specialized field of knowledge, one that requires extensive education, whether one is a physician, a nurse, or a technician of one type or another. The practical wisdom developed by good caregivers is more than just wisdom developed by experience. It is grounded in highly technical understanding of human physiology and the various methods of responding to health and illness. Because of this, caring in the health care context depends crucially on the social structures that make that knowledge possible, and on the systems of health care provision developed to make the provision of care possible and effective. These social structures and systems themselves, then, are essential parts of the provision of care, and deserve careful analysis in terms of their capacity to provide the care they are intended for.

Providing care is an essential part of human life, particularly the child care without which the species would cease to exist. One would expect that the sort of work I have been describing as care work, both private and professional, might get more respect than it does precisely because of its centrality to human existence (Held, 1993). It hasn’t, however, and the lack of attention to care work in philosophy seems to be over-determined by a large number of factors. Philosophy has historically been considered the province of men. Though women have obviously contributed, their voices are relatively few and far between, and frequently erased from the subsequent history (McAlister, 1996; Lerner, 1993). But it is not just women’s presence that is erased from Western philosophy. Entire areas of life that are relegated to spheres associated with women (whether the ‘private’ or the ‘domestic’ or issues involving children or the education of the young) are either treated as not philosophically interesting, or simply ignored as being outside the realm of important parts of human life (Okin, 1979; Elshtain, 1981; Nye, 1988). Philosophers in the past who have focused on issues of the education of young children, such as Plato and Rousseau, generally advocate protecting them from the pernicious effects of their female caregivers so that the more rational males can educate them properly (Green, 1995).

So, women’s voices are marginalized and erased, and the areas associated with them are ignored or criticized, rarely treated as areas where expertise relevant to philosophical thought might be found. The modern legacy of this traditional blindness is a general tendency for philosophers to simply fail to see that an account of human nature that ignores care work is lacking an important component, or to assume without reflection that matters pertaining to children or the elderly are simply irrelevant for general ethical theorizing. As Virginia Held notes, discussing the practices of child care:

That this whole vast region of human experience can have been dismissed as ‘natural’ and thus as irrelevant to morality is extraordinary. It may be outside moralities built entirely on abstract rationality, modeled as these are on an abstraction of the supposed ‘public’ realm. But that only shows how deficient these moralities are for the full range of human experience.

(1993, p. 36)

The development of an ethics of care, then, is in part a very deliberate attempt to develop an ethical theory that attends to the full range of human lives, from birth to death, as it is experienced by both caregivers and care receivers, and as it is experienced by actual embodied humans rather than disembodied rational egos or abstract calculating machines.

A word is probably in order here about the notion of essentialism. So far, I have spoken of women’s voices, of the social practices that are largely relegated to women, and the like. I am speaking in generalities here—obviously, some men have engaged in practices of care, and the voices of the women that entered philosophical conversations in earlier generations were almost exclusively women of the upper class with extraordinary privilege and few caregiving responsibilities. Critics of an ethics of care have frequently pointed to such issues in charging care ethics with an incipient essentialism. According to such critics, care ethics mistakenly attributes certain types of characteristics to women on the basis of their sex, and assumes that it is somehow a part of women’s nature to act and feel in certain ways, and so on.¹

But as has been pointed out numerous times, the recognition that certain tasks are socially allocated to women (or to men) hardly requires an essentialist position. Further, recognizing that the social position (whether privileged or not) that a woman (or a man) occupies is likely to have an effect on her perspective is also not essentialist (Hartsock, 1999). One might also point out that paying attention to the way that social groups are positioned with respect to socially powerful roles is a central part of feminist theory, as the large number of anti-essentialists who have resorted to ‘strategic essentialism’ in order to continue to advocate for women’s rights suggests (Stone, 2004). In any case, since the question of essentialism is not central to the focus of this book, and since a care ethics analysis does not need to take a stand one way or another on the issue, for my purposes here I will assume that the capacity to care is an essential human attribute, but not necessarily a gendered one, and that one’s capacity to care is developed by engaging in practices of care on a regular basis. Women’s caring activities, thus, are relevant to, but not definitive of, caring practices. Any account that ignores them, however, is an incomplete moral theory. This also indicates another reason why care ethics is particularly important for thinking about health care. Many discussions of medical ethics assume that ethical matters in medicine involve physicians (a stereotypically masculine role) and patients. The central role of nurses in the practice of medicine is strangely absent from many analyses. An ethics of care offers a perspective from which to rectify this omission.

Care and Empathy

Because an ethics of care focuses on the character traits, epistemological skills, and capacities such as attentiveness developed by practices of care, an ethics of care will have more in common with virtue accounts of ethics than with either a rationalist/deontological or a universalist consequentialist conception of ethics. While rational deliberation is an important component of ethical practice, from an ethics of care standpoint, the use of rationality will not require the squelching or erasure of emotional responses. On the contrary, an ethics of care has clear connections to the many historical figures (Hume, Aristotle, Augustine) who emphasize the centrality of emotions to the moral life, and a number of feminist theorists have noted these connections (Baier, 1994; Nussbaum, 2001; Groenhout, 2004; Slote, 2007). The particular emotions connected with practices of care, such as empathy, love, and the concern evoked by observing vulnerability in another, are clearly central to an ethics of care: Nel Noddings considers these the natural basis upon which an ethics can be built (Noddings, 1984). Other theorists such as Michael Slote consider empathic caring to be the central feature that makes a response truly moral (Slote, 2007). Nursing theory has also noted the importance of both intellectual and affective components of good care (Bishop and Scudder, 1991) and some theorists in medicine have likewise noted the necessity of empathetic responses for good care (Halpern, 2001) and the ways that the structures of medicine can make caring difficult (Brody, 1992).

Empathy is the capacity to feel with another, to recognize and resonate with another’...

Table of contents

• Cover
• Half Title
• Series
• Title
• Copyright
• Dedication
• Contents
• Acknowledgments
• Introduction: Care and Social Structures
• 1 Care Ethics and the Practice of Medicine
• 2 Medical Knowledge: From Clinical Judgment to Evidence-Based Practice
• 3 Public Health and Free Markets
• 4 Care and the Technological Imperative
• 5 Authority and Power in Medicine
• 6 Conclusions: Care, the Ends of Medicine, and the End of Life
• Bibliography
• Index