Dimensions/phases of care
Ethical attitude
Caring about – This involves the ‘recognition that care is necessary’ and includes concern, worry about someone or something. This could include making a donation to a charity where a need has been recognised.
Attentiveness – noticing need for care
Taking care of – This next step of the caring process involves taking responsibility for tasks relating to the provision of care and looking after someone. This could include arranging care for a child or elderly relative.
Responsibility – to improve the situation of someone
Care-giving – The ‘direct meeting of care needs’ involves delivering care to someone and includes the activities of nurses and other care-givers.
Competence – having the knowledge, skills and values necessary to meet the goals of care
Care-receiving – This final phase of care focuses on the care-recipient, on the difference care makes and on their response to care and their feedback.
Responsiveness – saying ‘thank you’, responding positively to care delivery
People ‘care about’ many issues, individuals and artefacts, however, they may go no further than notice a need for care. ‘Taking care of’ requires more of an investment. It requires taking responsibility to improve the situation of another. This could involve making a donation to a charity or, more personally, making arrangements for a loved one to receive care from a domiciliary, residential or day care facility. The third phase – ‘care-giving’ – requires a direct engagement with care. It requires competence to deliver care adequately. The fourth phase of ‘care-receiving’ involves the responsiveness of those receiving care where, that is, they are able to provide a response. Those who are unconscious, who are psychotic, too young or who have severe dementia may be unable to appreciate the experience of receiving care or to recognise the difference care makes.
Regarding the role of care and caregivers, Tronto (1993 p. 117) clearly articulates the importance and devaluation of care in society. Her view clearly also has a political dimension:
Care is difficult work, but it is the work that sustains life […] The fact that care-givers can see an essential truth about the value of care, though, does not negate the fact that care is reduced to a lesser importance in society as a whole. When we look at the distribution of such rewards as money and prestige, it is clear that we value much else before care.
To recognise the value of care calls into question the structure of values in our society. Care is not a parochial concern of women, a type of secondary moral question, or the work of the least well off in society. Care is a central concern of human life. It is time that we began to change our political and social institutions to reflect this truth (p. 179).
Despite a recognition of the importance of care, it is sometimes the case that there are care deficits where care recipients are neglected, humiliated and abused (Francis 2013; Bubb 2014). Some of these violations may arise, according to Tronto, when there are inadequate resources or when the caregivers’ own needs are unmet. They may come to resent the care-recipients they are charged with delivering care to. Tronto writes (Tronto 1993 p. 143):
[…] care-givers are often enraged about their own unmet needs. If they are unable to recognise this rage, care-givers are likely to vent their anger on those for whom they care. Perhaps some rage is appropriate, but when it subverts the process of care itself, then it poses a serious moral problem.
The theme of care deficits and mistreatment is also examined by Eva Feder Kittay (Kittay 2002), most particularly in relation to institutional care for those with learning disabilities. She argues that where caregivers are exploited they may become ‘victimisers’ as well as victims. ‘In such a society’, she writes, ‘care will be minimal, and callous caretakers will be inevitable’ (p. 269). She goes on to say:
[…] abusive behaviour by those who are charged with providing care is facilitated not only by the social devaluation of persons with mental disabilities, but also by the devaluation of the caregivers themselves. If we want to remove the prejudice and lack of understanding that blights the lives of people with mental retardation we can begin by treating their caregivers as if their work mattered (because it does) and as if they mattered (because they do). To do this we need to provide caregivers with conditions that allow them to do their work well and receive just compensation […] compensation that matches the intensity of their labour, and encouragement in their sympathetic and empathic responses to their charges (p. 270).
Caring for the caregivers is an understandable and important priority. So too, is understanding the reasons for unethical behaviour in care practices. This is particularly pressing in the light of recent high profile care scandals. What is most helpful from the perspectives of Tronto and Kittay is the extension of explanations beyond individual blame to societal and political explanations. Tronto’s (2013) recent work has developed what Barnes et al. (2015 p. 4) refer to as ‘the political character of feminist virtue ethics’. The next section discusses the perspective of a European philosopher and theologian who is well known for his work in nursing ethics.
Perspectives on Care Ethics: Chris Gastmans
Chris Gastmans has been actively involved in researching philosophical and empirical aspects of ethics as applied to care for over two decades. His research and scholarship has been influential in interpreting elements of care ethics for everyday nursing practice (see, for example, Gastmans et al. 1998, Gastmans 1999, Vanlaere and Gastmans 2011, and Gastmans 2013). Three of his papers will be the focus of this section: collaborative work with de Casterlé and Schotsmans on nursing as a moral practice and the concepts of ‘good care’ (Gastmans et al. 1998); and more recent writing on ‘dignity-enhancing care’ (Gastmans 2013).
In the 1998 article, Gastmans, de Casterlé and Schotsmans develop a model for ‘nursing considered as a moral practice’ with three main components: the caring relationship (a condition of nursing practice); caring behaviour (‘integration of virtue and expert activity) and ‘good care’ described as ‘the final goal of nursing practice’. Regarding the caring relationship, Gastmans et al. (1998) discuss the perspectives of the nurse as care giver and the care recipient. They write:
Caring generally can be considered as a specific way of relating oneself to the other in a relational context, with attention given to the maintenance and the development of the other (patient) and oneself (nurse) (p. 49).
Gastmans and his co-authors emphasise the otherness of the patient and the importance of recognising the uniqueness and value of the patient with a view to helping him/her to grow and to maximise ‘his or her own life development’ (p. 49). An important feature of this discussion is the focus on self-care. It is argued that nurses need to care for themselves if they are to care well for patients. Building on the work of Tronto (1993) and Noddings (1984), they argue that care receivers play an important part in the way care is interpreted and judged in relation to their care needs. Caring behaviour, according to Gastmans et al. (1998), involves the integration of virtue (altruistic virtue of care with cognitive and affective-motivational features) and expert activity (including technical competencies).
Nursing is defined as:
[…] a relation-based practice that is directed to providing good care to (usually sick) human beings (p. 52).
For Gastmans and his co-authors, ‘good care’ is the ‘goal and foundation of nursing practice’. To better understand and illuminate what is meant by ‘good care’, they draw on European philosophical perspectives on ‘being human’ (p. 59). Their approach elaborates on six dimensions of the patient: the physical; the relational; the social; the psychological; the moral; and the spiritual. Understanding the concept of ‘good care’ is also described as requiring engagement with insights from psychology, philosophy, sociology, nursing and medicine. Overall, then, nursing is described as a practice with three components: the caring relationship; the integration of virtue and expert activity; and ‘good care as the goal of nursing practice’. Good care involves engagement with six dimensions. Gastmans and colleagues argue that:
Care is more than simply the sum of the various aspects that can be differentiated in the concept. A comprehensive description of good care involves a number of dimensions and is not simply the juxtaposition of detached properties and domains of thought. Constructing an ethical concept such as good care is impossible without drawing on data from the diverse human sciences such as philosophy, psychology, sociology, nursing science and medicine. But from an ethical point of view, the various components cannot be considered separately from each other – they influence and invoke each other. (Gastmans et al. 1998 p. 66).
Another version of care ethics, proposed by Chris Gastmans, is described as ‘dignity-enhancing care’ (Gastmans 2013). The three core ideas or concepts are proposed as central: dignity, care and vulnerability. Gastmans writes that much scholarship in medical ethics has focused on the four principles approach – respect for autonomy, beneficence, non-maleficence and justice. However, this approach (principlism) is concerned with questions such as ‘what is to be done?’ or ‘what act or decision is to be taken? […] Gastmans argues that care does not involve isolated decisions but rather that those ‘caring for patients go through a whole process of care’. He argues that we need to engage with three components: lived experience (vulnerability); interpretative dialogue (care process); and normative standard (dignity). These three components are aspects of an ‘ethical framework to inspire our reflection on the ethical essence of nursing’ (p. 146). Further interrogation is required in relation to each of these concepts and some of this will be developed in the next section.
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