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The trouble with caring: A review of eight arguments against an ethic of care
The Trouble With Caring: A Review of Eight Arguments Against an Ethic of Care NANCYJ. CRIGGER,PHD, RN*
Caring represents a large social movement that includes, but is not limited to, nursing. Some nurse scholars and feminists believe that caring can be used as the basis of a caring ethic, but critics argue that caring is not enough. This article reviews eight of the major arguments against a caring ethic and explores responses and alternatives to the arguments. (Index words: Caring; Caring ethic; Ethics; Feminism; Partiality) J Prof Nurs 13:217-221, 1997. Copyright © 1997 by W.B. Saunders Company
URSES' C O N C E R N about the dehumanizing and demoralizing effects of technology became clearly articulated in the early 1980s. Gadow (1984), one of many scholars troubled by the issue, contrasted her concern as two paradigms for nursing: the patient as machine and the patient as recipient of empathy. During the next decade, the movement to adapt an empathetic paradigm, a paradigm of"caring," steadily gained support (Sullivan & Deane, 1994). The change of nurses' image from professionals who "care for patients" to professionals who possess the quality of "caring" was not unique to nursing; rather, it was reflective largely of feminist theory development of the 1960s and 1970s. Philosophy, education, religion, applied ethics, and health care disciplines, like nursing, valued human care and described themselves as caring professions. The popularity of the caring movement resulted in a large body of eclectic literature. Caring literature is divided into three distinct areas: the epistemological or knowing, the ontological or being, and the ethical or prescriptive. Traditionally, ethical theories are categorized as virtue, principle, or teleologic. Some scholars believe that care represents a type of virtue ethic (Bottorff, 1991), whereas others believe it to be distinctly different from any traditional classification (Noddings, 1984).
Scholars from many diverse disciplines argue that an ethic of care cannot provide a satisfactory basis for a theory of ethical decision making (Nelson, 1992; Noddings, 1990). The purpose of this article is to explicate arguments against a caring ethic, many of which have not appeared in the nursing literature and thus are unfamiliar to nurses. In the final section a strategy for further development of a caring ethic is suggested.
N
*Assistant Professor,School of Nursing, Universityof Central Florida, Orlando, FL. Address correspondenceand reprint requests to Dr Crigger: University of Central Florida, School of Nursing, PO Box 162210, Orlando, FL 32816-2210. Copyright© 1997 byW.B. SaundersCompany 8755-7223/97/1304-0007503.00/0
Criticism No. 1
The current conceptualization of caring is too vague to support any substantial theory of nursing or the foundation for an ethic of care. ARGUMENT
Critics and advocates express concern that the lack of a consensus on the conceptual and practical clarity of care contributes to caring's notorious ambiguity. Historically, "care" has been used to describe many different mental states and behaviors (Bottorff, 1991). The recent increased interest in care has not made the meaning of the word any clearer. Each scholar's interpretation of care differs and adds to the ambiguity. The diversity of nurse scholars' interpretation of care is apparent. For example, Watson (1990) and Watson and Ray (1988), amid images of landscapes and windows, perceive caring as a powerful transpersonal event that frees the carer and the cared for from isolation. Watson's caring ethic is not as well articulated as that of Gadow (1988), who views care as a covenant or contract that involves . . . "the commitment to alleviating another's vulnerability" (p. 6). Nonnursing scholars have similar variances in their interpretations of care. Mayerhoff (1971), a philosopher and one of the earliest advocates of contemporary caring, defines caring as the attitude of wishing well and assisting in the growth of another person. His interpretation of care comes close to the conception of Christian agape, which is expressed as good will to others. Noddings (1984), who has articulated the
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most developed feminist theory of a caring ethic, believes caring to be the relationships in which one caring person responds to another. Caring occurs, according to Noddings, when an individual becomes attentive to or engrossed with another person and empathizes and responds by doing for him or her. With such diverse opinions, there is no firm point from which to build a shared language (Kuhn, 1973) and ultimately a paradigm for care or caring ethic. In addition to shared language, paradigms or theories should contain a substantive difference. What is the substantive element that sets caring apart from other paradigms or theories? Curzer (1993) attempted to answer this question through his analysis of the common, current usages of care. He first identified three common uses for "care": to minister to or to care for, to take a dispassionate interest in, and to have a liking for. Through a convincing argument, Curzer showed that the only usage consistent with nursing and feminist theory are instances of the third kind, ie, having a liking for. In the first instance, to minister to a person, is the usage of traditional nursing. Nurses provide a service for patients; nurses do things for patients that they can not do for themselves. Adherence to standards of nursing practice are good examples of "caring for" a patient. Standards set the basic behaviors expected of a nurse without any reference to the nurses' internal response. The nurse who meets the standards of behavior is considered a good nurse. Curzer's second usage of "care" occurs if an individual shows interest in things or people. As with the first usage, interest does not require liking the thing or person. This dispassionate type of caring means that something is merely an object of attention. Heidegger's (1962) described caring in this way, as morally neutral but something that matters. In the first two usages, human value and worth can be maintained without an affective or emotional element. Only the third usage of care is, according to Curzer (1993), substantive and consistent with the feminists' and nurse theorists' conceptualization of caring. Adding passion or emotion--the liking of another--is distinctively different from both the first and second usages. Therefore, Curzer reasoned, the substantive element of caring requires that caring be conceptualized as an emotional responsiveness. Is there hope of developing a shared language and paradigm of care for nursing? Nelson (1992), one of the most outspoken of the critics of nursing's use of "care," doubts that unification is possible. She writes, "I should like to propose that the work of grounding a
NANCY J. CRIGGER
nursing theory in the ethics of care be postponed indefinitely . . . it is incapable of doing the work nurses need it to do" (p. 9). Fortunately, the majority of scholars are more hopeful than Nelson (1992). They acknowledge that the difficulty in developing a caring theory or paradigm is ahead but, unlike Nelson, that the effort will be fruitful (Bottorff, 1991). Criticism No. 2
Caring leads to exploitation of the caregiver. ARGUMENT
According to some critics (Card, 1990; Hoagland, i990; Morse, Solberg, Neander, Bottorff, & Johnson, 1990), an ethic of care sets up the potential for exploitation and abuse of the person who cares. The possibility of exploitation is clear in Noddings' theory of care and can be used as an exemplar. Noddings (1984), like Aristotle (500 B.C./1984), identifies two types of relationships: equal and unequal. A healthy caring relationship of equals, Noddings claims, is a mutually satisfying and empowering relationship. Unequal relationships, on the other hand, occur if the caring person gives more to the relationship than the other. Some unequal relationships--teacher and student, parent and child--are healthy and appropriate. At times, teachers or parents may sacrifice their desires or needs for the good of their child or student, and the sacrifice is perfectly healthy. Unequal relationships become unhealthy when individuals subordinate their desires to another person who exploits them. In our culture, codependency is the model for unhealthy, unequal relationships. Noddings (1992) acknowledged and labeled unequal expletive relationships as "pathological caring" (p. 16). Under normal circumstances, why would nurses allow themselves to be harmed or to compromise their own moral standards in pathological caring? According to Caffrey and Caffrey (1994), nurses, the large majority of whom are women, have been socialized to believe that their role in many relationships is selfsacrificial (Caffrey & Caffrey, 1994; Heidigger, 1962). Nelson (1992) suggests that the caring person may lose her own identity and become enmeshed in the relationship. Certainly, Watson's (1990) description of caring as . . . "the nurse . . . form(s) a union with the other person that transcends the physical . . ." (p. 66) and Noddings' (1984) a s . . . "I begin as nearly as I can with the view from his eyes . . . from that point we struggle together" (p. 24) suggest enmeshment. Noddings (1992) denies that her theory leads to enmeshment but believes that caring involves more than
THE TROUBLE WITH CARING
attention to and intellectual involvement with another. The argument that caring can lead to enmeshment and exploitation clearly is valid. Further development of a caring ethic can delineate healthy from unhealthy relationships and limit caring to healthy relationships. Caffrey and Caffrey (1994) suggest a number of good strategies for combating codependency in nursing in their timely article. Criticism No. 3 An ethic of care does not solve ethical conflicts. ARGUMENT
Some authors claim that any ethical theory of caring would be a subjectivist theory (Gaul, 1995; Puka, 1988). A subjectivist makes decisions based on his or her emotional responses without regard to principles, duties, or facts. For example, two siblings whose mother is in an irreversible coma, love and care for her. One of the siblings decides that the mother should be removed from artificial life support (there are no advance directives), whereas the other decides that the mother should be maintained on life support. In this situation, both of the children care, but caring alone has no power to resolve the moral conflicts. Subjectivism is mentioned briefly in the nursing literature (Sullivan &Deane, 1994), and historically no resolution to subjectivism has been identified in the philosophical literature (Hare, 1981).
According to some critics,.., an ethic of care sets up the potential for exploitation and abuse of the person who cares.
Criticism No. 4 Caring as the sole basis for a moral decisions leads to relativism. ARGUMENT
The arguments against a relativistic ethical theory also apply to an ethic based solely on care (Gaul, ! 995; Hare, 1981). Relativism occurs if there are no absolutes on which to base a moral decision; it can lead to immoral decisions. Some scholars believe tha~ the proper solution is augmentation: caring should be combined with traditional moral theories (Gaul, 1995; Noddings, 1990).
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Criticism No. 5 A relational ethic of caring is not just; it is based on partiality or favoritism.
ARGUMENT
Two major problems with partiality have been well described historically (Ashmore, 1987; Card, 1990; Cottingham, 1983). How one should treat people that one does not like? If nursing actions are based on caring for another, there will be partiality because human beings develop relationships that are as individual as the two people involved. Often partiality is appropriate, but it must be balanced with other elements, such as justice or duty. If partiality is unrestrained, unethical choices and, subsequently, unethical actions can occur. Take the case of Nurse L., who is assigned to a frail, elderly woman who reminds her of her grandmother. Nurse L. develops a caring relationship with the patient. A second patient reminds Nurse L. of her stepfather, whom %he hates, and Nurse L. is unable to establish a caring relationship with him. Nurse L. nurses both patients, but she is unable to care equally for the two patients. Is it moral for Nurse L. to provide more care to the first patient than she does to the second? In an ethical theory of care, this would be ethical, because Nurse L. has established a caring relationship with the first but not the second patient. Along these same lines, feminist scholars express concern about the limited scope of caring. An ethic that exists only by caring relationships means that one has no moral obligation to persons unless one has a personal relationship with them (Card, 1990; Houston, 1990). If an ethic is relationship, then we have no obligation to people starving in India or to the homeless in Seattle. Claudia Card (1990), a noted feminist philosopher, calls the limited scope issue "the problem of the stranger" and believes that one's concern should extend beyond the limits of our individual relationships to include others with whom we have no personal relationships. Caring outside of a relationship is not possible in theories of a caring ethic. What can mitigate the problem of partiality in caring theory? Some scholars advocate infusing social justice or impartiality, thus balancing the partiality of caring (Card, 1990; Crigger, 1994; Curzer, 1993; Houston, 1990; Puka, 1988), whether by the use of traditional moral theory or through extension of an ethic of care (Noddings, 1990).
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Criticism No. 6
The intensity of caring described by nurse and feminist theorists may not be desired by the patient nor practical for the nurse. ARGUMENT
The practical problem of intensity has been explored by both Curzer (1993) and Kuhse (1993). Kuhse claims that descriptions given by many nurse and feminist theorists imply that a caring relationship is intense and absorbing. As Van Hooft (1987) concluded after study of Mayeroff and Buber, the type of intense and intimate relationship described seemed appropriate for people in love but inappropriate for a nurse-patient relationship. Kuhse explored the practical problems resulting from high-intensity caring. Could the nurse, given that he or she cares for many patients in the course off a day, be capable of sustaining that level of intensity for all patients assigned? Both Kuhse (1993) and Curzer (1993) commented that this high expectation, although noble, has no basis in reality, and, furthermore, it may contribute to burn-out. Conversely, the patient may not wish to have an intense relationship with the nurse. In the review of the literature, no counter argument was offered for this criticism. Criticism No. 7
Caring may focus too much on the nurse and not enough on the patient. ARGUMENT
This particular criticism is discussed only briefly by Melia (1994). She fears that nurses may become so involved with the theoretical development of an ethic of care that they fail to stay practice oriented. Melia believes that an ethic of care must be generated by the patient's experience of caring, ie, that experience may be overlooked if care is focused on caring as a quality of the nurse. She advocates the use of ethnography for study of both patient and nurse experiences of caring. Virtue is an inward character or disposition rather than an outward feature of conduct (Baler, 1982). If the nurse relies on virtue to determine if a decision is moral, then the outcome, or what happens to the patient, would be morally neutral. In other words, theories based on virtue and principle as a basis for ethical decision making do not consider the outcomes of a decision, whereas teleological ethical theories do. Morse et al., (13) also express concern for the forgotten patient, but they do not describe their basis for this criticism. The solution might be a more
moderate virtue ethic than can be used in conjunction with other traditional ethics. Frankena, some time ago (1973), suggested combining ethical theories for a viable alternative: "I propose . . . that we regard the morality of principles and the morality of character, or doing and being, not as rival kinds of morality between which we must choose, but as two complementary aspects of the same morality" (p. 53).
Criticism No. 8
If caring is an emotional response, it may hinder health care professionals' ability to "care for" their patients. ARGUMENT
Curzer (1993) believed that at times emotional responsiveness may hinder rather than help. He identified two reasons why patient care might be compromised if caring requires emotional responsiveness. Curzer (p. 60) writes: .. doctors are warned not to treat themselves, their family members, or their friends as patients. They are too emotionally attached . . . . Their caring prevents them from providing the best medical care... Therefore, it seems bizarre to suggest that HCP (health care professionals) should care for their patients, for this implies that they should abandon their objectivity, compromise their professional judgment and ... decline to provide their patient with the best medical care. •
In addition to potential for altered treatment, Curzer (1993) bdieves that emotional responsiveness leads to paternalism on the part of the health care professional. Paternalism, Curzer claims, is more likely to occur with people with whom one has emotional ties.
Conclusions
Arguments against an ethic of care are the longstanding philosophical ones against partiality, virtue ethics, relativism, and subjectivism. The Practical arguments of paternalism and human limitations also pose difficult problems for a caring ethic. Many of the arguments have no good solutions to combat their weaknesses. If the arguments against caring as a basis for ethical theory are invalid, then debate is needed to expose fallacies of the arguments. Nursing scholars turn from enriching our knowledge of caring through expositional writing to grapple with the problems of caring through literary argument. If the criticisms
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against caring are valid, what can be done? Are the problems insurmountable? Some critics believe that caring is so limited as an ethical basis that the idea should be discarded completely (Curzer, 1993; Nelson, 1992; Puka, 1988). Others suggest different central terms for building an ethic, such as empathy (Olsen, 1990), therapeutic reciprocity (Marck, 1990), loving attention (Nelson, 1992), detached concern (Curzer, 1993), and reflective equilibrium (Nussbaum, 1987). Yet a third group advocates caring as an adjunct to, rather than an
alternative for, already existing ethical theories (Brody, 1988; Crigger, 1994; Gaul, 1995; Melia, 1994; Salsberry, 1992). One truth seems clear. Advancement of a caring paradigm and an ethic of care is possible if nurse scholars are willing to suspend their own partiality toward a caring paradigm and to objectively examine the criticisms. If the criticisms are unfounded, then refutation is in order. However, if legitimate problems exist, criticism brings us one step closer to developing a viable ethic of care.
References
Aristotle. (500 B.C./1984). The complete works of Aristode. J. Barnes (Ed.), The Revised Oxford Translation, Vol. 2. Princeton, NJ: Princeton University Press. Ashmore, R. B. (1987). Building a moral system. Englewood Clifs, NJ: Prentice Hall. Baier, K. (1982). Virtue ethics. PhilosophicalExchange, 3, 57-70. Bottorff, J. L. (1991). Nursing: A practical science of caring. Advances in Nursing Science, 14(l), 26-39. Brody, J. K. (1988). Virtue ethics, caring, and nursing. Scholarly Inquiry for Nursing Practice: An International Journal, 2, 87-96. Caffrey, R. A., & Caffrey, E A. (1994). Nursing: Caring or codependent? Nursing Forum, 29(1), 12-17. Card, C. (1990). Caring and evil. Hypatia, 5(1), 101107. Cottingham, J. (1983). Ethics and impartiality. Philosophical Studies, 43, 83-99. Crigger, N. J. (1994). Noddings' theory of caring: Alternative or complement to traditional moral theory? Unpublished thesis, University of Florida, Gainesville. Curzer, H. J. (1993). Is care a virtue for health care professionals? The Journal of Medicine and Philosophy, 18, 51-69. Frankena, W. K. (1973). Ethics (2nd Ed.). Englewood Cliffs, NJ: Prentice-Hall. Gadow, S. (1984). Touch and technology: Two paradigms of patient care. Journal of Religion and Health, 23(1), 59-69. Gadow, S. (6). Covenant without cure: Letting go and holding on in chronic illness. In J. Watson & M. A. Ray (Eds.), The ethics of care and the ethics of cure: Synthesis in chronidty (pp. 5-14). New York: National League for Nursing. Gaul, A. L. (1995). Casuistry, care, compassion, and ethics data analysis. Advances in Nursing Science, 17(3), 47-57. Hare, R. M. (1981). Moral thinking. Oxford, England Clarendon. Heidegger, M. (1962). Being and time. New York: Harper & Row. Hoagland, S. L. (1990). Some concerns about Nel Noddings' caring. Hypatia, 5(1), 109-113. Houston, B. (1990). Some concerns about Nel Noddings' caring. Hypatia, 5(1 ), 115-120.
Kuhn, T. S. (1973). This structure of scientific revolutions. Chicago: University of Chicago Press. Kuhse, H. (1993). Caring is not enough: Reflections on a nursing ethics of care. Australian Journal of Advanced Nursing, 11(1), 32-42. Marck, P. (1990). Therapeutic reciprocity: A caring phenomenon. Advances in Nursing Science, 13(1), 49-59. Mayeroff, M. (1971). On caring. New York: Harper and Row. Melia, K. M. (1994). The task of nursing ethics. Journal of Medical Ethics, 20, 7-11. Morse, J. M., Solberg, S. M., Neander, W. L., Bottorff, J. L. &Johnson, J. L. (1990). Concepts of caring and care as a concept. Advances in Nursing Science, 13(1), t-14. Nelson, H. L. (1992). Against caring. The Journal of ClinicalEthics, 3(1), 8-14. Noddings, N. (1984). Caring. Berkeley, CA: University of California Press. Noddings, N. (1990). A response. Hypatia, 5(1), 120126. Noddings, N. (1992). In defense of caring. TheJournaI of Clinical Ethics, 3(1), 15-17. Nussbaum, M. (1987). Perceptive equilibrium: Literary theory and ethical theory. Logos: Philosophic Issues in Christian Perspective, 8, 55-83. Olsen, D. E (1990). Empathy as an ethical and philosophical basis for nursing, Advances in Nursing Science, 14(1), 62-75. Puka, B. (1988). Ethical caring and development: Pros, cons and possibilities. In S. H. Lee (Ed.), Inquiries into values (pp. 99-113). In Journal Lewiston, Mdlen Proceedings. Salsberry, P. J. (1992). Caring, virtue theory, and a foundation for nursing ethics. Scholarly Inquiry for Nursing Practice: An International Journal, 6(20), 155-167. Sullivan, J. L., & Deanne, D. M. (1994). Caring: Reappropriating our tradition. Nursing Forum, 29(2), 5-9. van Hooft, S. (1987). Caring and professional commitment. Australian Journal of Advanced Nursing, 4(4), 30-31. Watson, J. (1990). Caring knowledge and informed moral passion. Advances in Nursing Science, 13(1), 15-24. Watson, J., & Ray, M. A. (1988). The ethics of care and the ethics of cure: Synthesis in chronicity. New York: National League for Nursing.
Caring represents a large social movement that includes, but is not limited to, nursing. Some nurse scholars and feminists believe that caring can be used as the basis of a caring ethic, but critics argue that caring is not enough. This article reviews eight of the major arguments against a caring ethic and explores responses and alternatives to the arguments. (Index words: Caring; Caring ethic; Ethics; Feminism; Partiality) J Prof Nurs 13:217-221, 1997. Copyright © 1997 by W.B. Saunders Company
URSES' C O N C E R N about the dehumanizing and demoralizing effects of technology became clearly articulated in the early 1980s. Gadow (1984), one of many scholars troubled by the issue, contrasted her concern as two paradigms for nursing: the patient as machine and the patient as recipient of empathy. During the next decade, the movement to adapt an empathetic paradigm, a paradigm of"caring," steadily gained support (Sullivan & Deane, 1994). The change of nurses' image from professionals who "care for patients" to professionals who possess the quality of "caring" was not unique to nursing; rather, it was reflective largely of feminist theory development of the 1960s and 1970s. Philosophy, education, religion, applied ethics, and health care disciplines, like nursing, valued human care and described themselves as caring professions. The popularity of the caring movement resulted in a large body of eclectic literature. Caring literature is divided into three distinct areas: the epistemological or knowing, the ontological or being, and the ethical or prescriptive. Traditionally, ethical theories are categorized as virtue, principle, or teleologic. Some scholars believe that care represents a type of virtue ethic (Bottorff, 1991), whereas others believe it to be distinctly different from any traditional classification (Noddings, 1984).
Scholars from many diverse disciplines argue that an ethic of care cannot provide a satisfactory basis for a theory of ethical decision making (Nelson, 1992; Noddings, 1990). The purpose of this article is to explicate arguments against a caring ethic, many of which have not appeared in the nursing literature and thus are unfamiliar to nurses. In the final section a strategy for further development of a caring ethic is suggested.
N
*Assistant Professor,School of Nursing, Universityof Central Florida, Orlando, FL. Address correspondenceand reprint requests to Dr Crigger: University of Central Florida, School of Nursing, PO Box 162210, Orlando, FL 32816-2210. Copyright© 1997 byW.B. SaundersCompany 8755-7223/97/1304-0007503.00/0
Criticism No. 1
The current conceptualization of caring is too vague to support any substantial theory of nursing or the foundation for an ethic of care. ARGUMENT
Critics and advocates express concern that the lack of a consensus on the conceptual and practical clarity of care contributes to caring's notorious ambiguity. Historically, "care" has been used to describe many different mental states and behaviors (Bottorff, 1991). The recent increased interest in care has not made the meaning of the word any clearer. Each scholar's interpretation of care differs and adds to the ambiguity. The diversity of nurse scholars' interpretation of care is apparent. For example, Watson (1990) and Watson and Ray (1988), amid images of landscapes and windows, perceive caring as a powerful transpersonal event that frees the carer and the cared for from isolation. Watson's caring ethic is not as well articulated as that of Gadow (1988), who views care as a covenant or contract that involves . . . "the commitment to alleviating another's vulnerability" (p. 6). Nonnursing scholars have similar variances in their interpretations of care. Mayerhoff (1971), a philosopher and one of the earliest advocates of contemporary caring, defines caring as the attitude of wishing well and assisting in the growth of another person. His interpretation of care comes close to the conception of Christian agape, which is expressed as good will to others. Noddings (1984), who has articulated the
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most developed feminist theory of a caring ethic, believes caring to be the relationships in which one caring person responds to another. Caring occurs, according to Noddings, when an individual becomes attentive to or engrossed with another person and empathizes and responds by doing for him or her. With such diverse opinions, there is no firm point from which to build a shared language (Kuhn, 1973) and ultimately a paradigm for care or caring ethic. In addition to shared language, paradigms or theories should contain a substantive difference. What is the substantive element that sets caring apart from other paradigms or theories? Curzer (1993) attempted to answer this question through his analysis of the common, current usages of care. He first identified three common uses for "care": to minister to or to care for, to take a dispassionate interest in, and to have a liking for. Through a convincing argument, Curzer showed that the only usage consistent with nursing and feminist theory are instances of the third kind, ie, having a liking for. In the first instance, to minister to a person, is the usage of traditional nursing. Nurses provide a service for patients; nurses do things for patients that they can not do for themselves. Adherence to standards of nursing practice are good examples of "caring for" a patient. Standards set the basic behaviors expected of a nurse without any reference to the nurses' internal response. The nurse who meets the standards of behavior is considered a good nurse. Curzer's second usage of "care" occurs if an individual shows interest in things or people. As with the first usage, interest does not require liking the thing or person. This dispassionate type of caring means that something is merely an object of attention. Heidegger's (1962) described caring in this way, as morally neutral but something that matters. In the first two usages, human value and worth can be maintained without an affective or emotional element. Only the third usage of care is, according to Curzer (1993), substantive and consistent with the feminists' and nurse theorists' conceptualization of caring. Adding passion or emotion--the liking of another--is distinctively different from both the first and second usages. Therefore, Curzer reasoned, the substantive element of caring requires that caring be conceptualized as an emotional responsiveness. Is there hope of developing a shared language and paradigm of care for nursing? Nelson (1992), one of the most outspoken of the critics of nursing's use of "care," doubts that unification is possible. She writes, "I should like to propose that the work of grounding a
NANCY J. CRIGGER
nursing theory in the ethics of care be postponed indefinitely . . . it is incapable of doing the work nurses need it to do" (p. 9). Fortunately, the majority of scholars are more hopeful than Nelson (1992). They acknowledge that the difficulty in developing a caring theory or paradigm is ahead but, unlike Nelson, that the effort will be fruitful (Bottorff, 1991). Criticism No. 2
Caring leads to exploitation of the caregiver. ARGUMENT
According to some critics (Card, 1990; Hoagland, i990; Morse, Solberg, Neander, Bottorff, & Johnson, 1990), an ethic of care sets up the potential for exploitation and abuse of the person who cares. The possibility of exploitation is clear in Noddings' theory of care and can be used as an exemplar. Noddings (1984), like Aristotle (500 B.C./1984), identifies two types of relationships: equal and unequal. A healthy caring relationship of equals, Noddings claims, is a mutually satisfying and empowering relationship. Unequal relationships, on the other hand, occur if the caring person gives more to the relationship than the other. Some unequal relationships--teacher and student, parent and child--are healthy and appropriate. At times, teachers or parents may sacrifice their desires or needs for the good of their child or student, and the sacrifice is perfectly healthy. Unequal relationships become unhealthy when individuals subordinate their desires to another person who exploits them. In our culture, codependency is the model for unhealthy, unequal relationships. Noddings (1992) acknowledged and labeled unequal expletive relationships as "pathological caring" (p. 16). Under normal circumstances, why would nurses allow themselves to be harmed or to compromise their own moral standards in pathological caring? According to Caffrey and Caffrey (1994), nurses, the large majority of whom are women, have been socialized to believe that their role in many relationships is selfsacrificial (Caffrey & Caffrey, 1994; Heidigger, 1962). Nelson (1992) suggests that the caring person may lose her own identity and become enmeshed in the relationship. Certainly, Watson's (1990) description of caring as . . . "the nurse . . . form(s) a union with the other person that transcends the physical . . ." (p. 66) and Noddings' (1984) a s . . . "I begin as nearly as I can with the view from his eyes . . . from that point we struggle together" (p. 24) suggest enmeshment. Noddings (1992) denies that her theory leads to enmeshment but believes that caring involves more than
THE TROUBLE WITH CARING
attention to and intellectual involvement with another. The argument that caring can lead to enmeshment and exploitation clearly is valid. Further development of a caring ethic can delineate healthy from unhealthy relationships and limit caring to healthy relationships. Caffrey and Caffrey (1994) suggest a number of good strategies for combating codependency in nursing in their timely article. Criticism No. 3 An ethic of care does not solve ethical conflicts. ARGUMENT
Some authors claim that any ethical theory of caring would be a subjectivist theory (Gaul, 1995; Puka, 1988). A subjectivist makes decisions based on his or her emotional responses without regard to principles, duties, or facts. For example, two siblings whose mother is in an irreversible coma, love and care for her. One of the siblings decides that the mother should be removed from artificial life support (there are no advance directives), whereas the other decides that the mother should be maintained on life support. In this situation, both of the children care, but caring alone has no power to resolve the moral conflicts. Subjectivism is mentioned briefly in the nursing literature (Sullivan &Deane, 1994), and historically no resolution to subjectivism has been identified in the philosophical literature (Hare, 1981).
According to some critics,.., an ethic of care sets up the potential for exploitation and abuse of the person who cares.
Criticism No. 4 Caring as the sole basis for a moral decisions leads to relativism. ARGUMENT
The arguments against a relativistic ethical theory also apply to an ethic based solely on care (Gaul, ! 995; Hare, 1981). Relativism occurs if there are no absolutes on which to base a moral decision; it can lead to immoral decisions. Some scholars believe tha~ the proper solution is augmentation: caring should be combined with traditional moral theories (Gaul, 1995; Noddings, 1990).
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Criticism No. 5 A relational ethic of caring is not just; it is based on partiality or favoritism.
ARGUMENT
Two major problems with partiality have been well described historically (Ashmore, 1987; Card, 1990; Cottingham, 1983). How one should treat people that one does not like? If nursing actions are based on caring for another, there will be partiality because human beings develop relationships that are as individual as the two people involved. Often partiality is appropriate, but it must be balanced with other elements, such as justice or duty. If partiality is unrestrained, unethical choices and, subsequently, unethical actions can occur. Take the case of Nurse L., who is assigned to a frail, elderly woman who reminds her of her grandmother. Nurse L. develops a caring relationship with the patient. A second patient reminds Nurse L. of her stepfather, whom %he hates, and Nurse L. is unable to establish a caring relationship with him. Nurse L. nurses both patients, but she is unable to care equally for the two patients. Is it moral for Nurse L. to provide more care to the first patient than she does to the second? In an ethical theory of care, this would be ethical, because Nurse L. has established a caring relationship with the first but not the second patient. Along these same lines, feminist scholars express concern about the limited scope of caring. An ethic that exists only by caring relationships means that one has no moral obligation to persons unless one has a personal relationship with them (Card, 1990; Houston, 1990). If an ethic is relationship, then we have no obligation to people starving in India or to the homeless in Seattle. Claudia Card (1990), a noted feminist philosopher, calls the limited scope issue "the problem of the stranger" and believes that one's concern should extend beyond the limits of our individual relationships to include others with whom we have no personal relationships. Caring outside of a relationship is not possible in theories of a caring ethic. What can mitigate the problem of partiality in caring theory? Some scholars advocate infusing social justice or impartiality, thus balancing the partiality of caring (Card, 1990; Crigger, 1994; Curzer, 1993; Houston, 1990; Puka, 1988), whether by the use of traditional moral theory or through extension of an ethic of care (Noddings, 1990).
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NANCY d. CRIGGER
Criticism No. 6
The intensity of caring described by nurse and feminist theorists may not be desired by the patient nor practical for the nurse. ARGUMENT
The practical problem of intensity has been explored by both Curzer (1993) and Kuhse (1993). Kuhse claims that descriptions given by many nurse and feminist theorists imply that a caring relationship is intense and absorbing. As Van Hooft (1987) concluded after study of Mayeroff and Buber, the type of intense and intimate relationship described seemed appropriate for people in love but inappropriate for a nurse-patient relationship. Kuhse explored the practical problems resulting from high-intensity caring. Could the nurse, given that he or she cares for many patients in the course off a day, be capable of sustaining that level of intensity for all patients assigned? Both Kuhse (1993) and Curzer (1993) commented that this high expectation, although noble, has no basis in reality, and, furthermore, it may contribute to burn-out. Conversely, the patient may not wish to have an intense relationship with the nurse. In the review of the literature, no counter argument was offered for this criticism. Criticism No. 7
Caring may focus too much on the nurse and not enough on the patient. ARGUMENT
This particular criticism is discussed only briefly by Melia (1994). She fears that nurses may become so involved with the theoretical development of an ethic of care that they fail to stay practice oriented. Melia believes that an ethic of care must be generated by the patient's experience of caring, ie, that experience may be overlooked if care is focused on caring as a quality of the nurse. She advocates the use of ethnography for study of both patient and nurse experiences of caring. Virtue is an inward character or disposition rather than an outward feature of conduct (Baler, 1982). If the nurse relies on virtue to determine if a decision is moral, then the outcome, or what happens to the patient, would be morally neutral. In other words, theories based on virtue and principle as a basis for ethical decision making do not consider the outcomes of a decision, whereas teleological ethical theories do. Morse et al., (13) also express concern for the forgotten patient, but they do not describe their basis for this criticism. The solution might be a more
moderate virtue ethic than can be used in conjunction with other traditional ethics. Frankena, some time ago (1973), suggested combining ethical theories for a viable alternative: "I propose . . . that we regard the morality of principles and the morality of character, or doing and being, not as rival kinds of morality between which we must choose, but as two complementary aspects of the same morality" (p. 53).
Criticism No. 8
If caring is an emotional response, it may hinder health care professionals' ability to "care for" their patients. ARGUMENT
Curzer (1993) believed that at times emotional responsiveness may hinder rather than help. He identified two reasons why patient care might be compromised if caring requires emotional responsiveness. Curzer (p. 60) writes: .. doctors are warned not to treat themselves, their family members, or their friends as patients. They are too emotionally attached . . . . Their caring prevents them from providing the best medical care... Therefore, it seems bizarre to suggest that HCP (health care professionals) should care for their patients, for this implies that they should abandon their objectivity, compromise their professional judgment and ... decline to provide their patient with the best medical care. •
In addition to potential for altered treatment, Curzer (1993) bdieves that emotional responsiveness leads to paternalism on the part of the health care professional. Paternalism, Curzer claims, is more likely to occur with people with whom one has emotional ties.
Conclusions
Arguments against an ethic of care are the longstanding philosophical ones against partiality, virtue ethics, relativism, and subjectivism. The Practical arguments of paternalism and human limitations also pose difficult problems for a caring ethic. Many of the arguments have no good solutions to combat their weaknesses. If the arguments against caring as a basis for ethical theory are invalid, then debate is needed to expose fallacies of the arguments. Nursing scholars turn from enriching our knowledge of caring through expositional writing to grapple with the problems of caring through literary argument. If the criticisms
THE TROUBLE WITH CARING
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against caring are valid, what can be done? Are the problems insurmountable? Some critics believe that caring is so limited as an ethical basis that the idea should be discarded completely (Curzer, 1993; Nelson, 1992; Puka, 1988). Others suggest different central terms for building an ethic, such as empathy (Olsen, 1990), therapeutic reciprocity (Marck, 1990), loving attention (Nelson, 1992), detached concern (Curzer, 1993), and reflective equilibrium (Nussbaum, 1987). Yet a third group advocates caring as an adjunct to, rather than an
alternative for, already existing ethical theories (Brody, 1988; Crigger, 1994; Gaul, 1995; Melia, 1994; Salsberry, 1992). One truth seems clear. Advancement of a caring paradigm and an ethic of care is possible if nurse scholars are willing to suspend their own partiality toward a caring paradigm and to objectively examine the criticisms. If the criticisms are unfounded, then refutation is in order. However, if legitimate problems exist, criticism brings us one step closer to developing a viable ethic of care.
References
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