Applying the Ethics of Care to Nursing Practice
Organisms vs. Persons: A Foundational Distinction
R.D. Laing's Perspective (The Divided Self): Differentiates one's relationship to an "organism" from one's relationship to a "person."
Organismic Study: Focuses on biological processes, such as neural processes and vocalizing apparatus when observing verbal behavior.
Personal Study: Aims to understand "what he is saying," starting from a relationship with the other as a person.
No Mind-Body Dualism: Laing explicitly states that this distinction does not imply a mind-body dualism. Both personal and organismic accounts are outcomes of initial intentional acts, each leading to different results and disclosing different aspects of human reality.
Methodological Choice: Investigators choose their point of view based on their objective "with the other." It is crucial to be aware of potential confusion when shifting between these perspectives.
Understanding Reductionism in Healthcare
Definition: Reductionism is the view that complex phenomena, including human experiences, consciousness, or personhood, can be fully explained by reducing them to their simpler constituent parts.
Reduction of Persons to Biological Processes:
Regards personhood primarily as a biological category.
Asserts that all aspects of human identity (thoughts, emotions, consciousness) are ultimately explainable by biological mechanisms (neural activity, genetic processes, biochemical interactions).
Consequences: Can lead to the elimination of other ways of understanding human beings.
Psychological, social, or moral dimensions are considered secondary or reducible to biological facts (e.g., love explained solely as chemical interactions in the brain rather than a complex emotional/social experience).
Reductionism and Medicine:
Third-Person Statements: Scientific and descriptive statements are always in the third person, ensuring an impartial and objective view.
Objectivity: This approach removes the individual researcher, shifting focus to experiments, observations, and results, which is what allowed science to become objective.
Challenge to Subjectivity: Poses a significant question: How do we approach subjectivity from a scientific point of view, and what is the place of first-person experience in science?
Bridging Subjectivity and Science: Phenomenology
Definition: Phenomenology is a branch of philosophy dedicated to studying first-person experience and the structure of consciousness.
Emphasizes how individuals encounter the world through their lived experience.
Key Figures:
Edmund Husserl: Founder of phenomenology.
Maurice Merleau-Ponty: Applied phenomenology to biological sciences, investigating the relationship between our embodied experience of the world and the physical body that experiences it.
Emmanuel Levinas: Focused on how the encounter with other people awakens a profound and infinite sense of moral responsibility.
Phenomenological vs. Biological Descriptions of Experience
This framework highlights how the same human experience can be understood through subjective, lived accounts and objective, biological explanations.
Pain:
Phenomenological: The subjective experience of discomfort or suffering; it might feel sharp, dull, or throbbing and is intimately tied to emotions like frustration or helplessness.
Biological: Pain originates when sensory nerves (\text{nociceptors}) detect injury. These signals travel to the brain, which processes location (sensory areas) and emotional responses (amygdala and other emotional areas).
Compassion:
Phenomenological: A feeling of empathy for another's suffering, coupled with a desire to help or alleviate their pain. The experience is deeply connected to the other's humanity.
Biological: Involves brain areas like the insula and anterior cingulate cortex, which facilitate understanding and feeling others' emotions. The hormone \text{oxytocin} strengthens social bonding.
Fear:
Phenomenological: The lived experience of dread, vulnerability, or a heightened sense of threat, frequently accompanied by a racing heartbeat or a sense of urgency.
Biological: Triggered by the amygdala, which activates the fight-or-flight response, leading to the release of \text{adrenaline} and \text{cortisol}, rapid heart rate, and physical preparation for action.
Joy:
Phenomenological: A subjective experience of delight or happiness, often described as a warm, expansive feeling tied to a sense of fulfillment or connection.
Biological: Occurs when the brain releases \text{dopamine} in reward systems. \text{Serotonin} helps stabilize mood, and \text{endorphins} boost pleasure.
Embodiment and Ethics: Virtue and Care Ethics
Shared Focus: Both Virtue Ethics and Care Ethics emphasize how individuals embody, live, and experience ethical reality and interpersonal relationships.
Prioritization: They prioritize contextual factors, lived experience, and the crucial role of emotions in ethical conduct.
Rejection of Abstract Deliberation: Both reject the notion that ethics is founded on abstract deliberation or "decision procedures" that can impersonally solve ethical dilemmas.
Personhood vs. Organism: They recognize that treating someone as a person fundamentally differs from treating them merely as an organism.
Moral Character: Focus on moral character as something to be cultivated and developed.
Habituation: Ethics involves habituation, for example, developing a "habit of care."
Interpersonal Foundations of the Ethics of Care
Tronto's Definition (\text{1993}): Defines caring as a "species activity that includes everything we do to maintain, continue and repair our "world" so that we can live in it as well as possible. That world includes our bodies, our selves and our environment, all of which we seek to interweave in a complex, life-sustaining web." (Tronto, p. \text{103}, \text{1993}).
Pre-Existing Moral Relationships: This definition assumes that all individuals are already in pre-existing moral relationships with each other.
Against Social Atomism: It opposes social atomism, the idea that individuals are intrinsically separate. Instead, it presumes a fundamental interconnectedness that forms the fabric of human lives.
Care as Fundamental to Human Existence
Crucial for Development: Care is essential for human development, initially focused on physical needs.
Biological Necessity: Necessary at the biological level for infants to survive and for dependent patients at the end of life.
Foundational Idea: Care ethics stems from the core idea that care is basic to human existence.
Network of Relationships: Caring weaves people into intricate networks of relationships (Vanlaere & Gastmans, \text{2011}).
Feminist Origins: Carol Gilligan's Contribution
Introduction: Care ethics was articulated by Carol Gilligan in her \text{1982} book, In a Different Voice.
Challenge to Traditional Theories: She challenged traditional moral theories, particularly Lawrence Kohlberg's stages of moral development, which emphasized justice, rules, and abstract reasoning.
Critique of Kohlberg's Model: Gilligan argued that Kohlberg's model was male-centric and failed to acknowledge women's moral reasoning, which often prioritizes care, relationships, and empathy.
Core Idea of Gilligan's Work: Moral decision-making is rooted in relationships and interdependence rather than universal principles. Care ethics highlights the importance of context and responsiveness to others' needs in ethical reasoning.
Core Tenets of Care Ethics in Nursing
Aim: Aims to "honour the human dimensions of nursing’s work and the inner life world and subjective experiences of the people we serve" (Lachman, \text{112}).
Relational Approach: A relational approach to ethics focusing on care as both a moral and a practical commitment.
Key Elements of Jean Watson’s Theory:
Carative Factors: Emphasize honoring human dimensions and subjective experiences. Examples include: "…developing and sustaining a helping-trusting, authentic caring relationship…" and "…being present to, and supportive of, the expression of positive and negative feelings as a connection with deeper spirit of self and the one-being cared-for…" (\text{112}).
Transpersonal Caring Relationship: Describes the nurse’s caring consciousness and moral commitment to intentionally connect with the patient (\text{112}).
Caring Moment: The specific time and space where the nurse and patient come together in a manner conducive for caring to occur.
Distinguishing Obligation-Based from Responsibility-Based Ethics
Obligations and responsibilities often overlap but address different aspects of ethical behavior.
Obligation-Based Ethics:
Focus: Centers on duties or rules (e.g., utilitarianism, deontology).
Rationality: Involves impartial reflection that focuses on context-independent rationality.
Assumptions: Presupposes social atomism, viewing people as intrinsically separate, isolated units that come together.
Example: A nurse's legal and professional obligation to follow protocols.
Responsibility-Based Ethics:
Starting Point: Begins with relationships and asks, "What is my responsibility to care in this specific situation?"
Responsiveness: Characterized by a "habit of care" that emphasizes responsiveness to specific contexts.
Assumptions: Presupposes social relationism/holism, understanding human beings as intrinsically related to one another.
Example: A nurse's sense of responsibility might motivate them to go beyond protocols to provide individualized care.
Core Difference: Responsibility-based ethics takes relationships as the starting point, while obligation-based ethics relies on abstract decision-making procedures.
Impartial Reflection vs. Situational Context in Ethical Decision-Making
Care Ethics Focus: Care ethics prioritizes the "context of the situation" over "impartial deliberation of the ethical issue." (\text{112}).
Impartial Reflection:
Definition: Equal consideration for all unless morally relevant differences exist.
Potential Drawback: Can become robotic and insensitive to context if applied blindly.
Foundation: Depends on the supposition that rationality is the most important aspect of moral decision-making.
Justice-Based: An element of justice-based moral deliberation, which often disregards the level of caring or closeness in relationships.
Situational Context:
Emphasis: Highlights the importance of specific relationships, circumstances, and the nuances of individual cases in ethical decision-making.
Challenge to Impartiality: Care ethics challenges impartiality by arguing that ethical decisions are profoundly influenced by relationships, emotions, and responsibilities unique to a given situation.
Interconnected Selves (Gilligan): Gilligan was instrumental in shifting moral theorizing from a position viewing selves as independent to one accepting them as interconnected and interdependent. Caring exists on a continuum, with varying levels of emotional involvement within a caring relationship.
Suppositions about Human Nature in Ethical Theories
Ethical theories often make implicit suppositions about human nature that inform their ethical stance.
Rationality vs. Empathy: Is rationality the most relevant dimension of human nature in ethical decision-making? Are humans fundamentally rational? Or is there value in employing other aspects like empathy?
Connectedness vs. Separation: Are humans intrinsically connected to one another, or intrinsically separate?
Variability in Caring: Why are some individuals inherently better at caring than others?
Developing Moral Vision
Definition: Moral vision refers to an individual's capacity to perceive and respond to the suffering of others.
Variations: Some individuals may suffer from "moral blindness," being unmoved by others' suffering, while others may have underdeveloped moral vision.
Importance in Nursing: A care orientation is fundamental to the nurse-patient relationship and is inherent to the nursing profession itself (Edwards, \text{2009}; Gastmans, \text{2006}).
Case Study: Mr. Jones and the Application of Care Ethics
Background: Mr. Jones, a \text{59}-year-old man, is admitted with acute abdominal pain and coffee-ground vomiting (indicating gastrointestinal bleeding). His medical history includes alcoholism, unmanaged diabetes, and a left below-the-knee amputation. He recently lost his wife of \text{40} years, leading to increased drinking and health neglect.
Challenge:
Mr. Jones presents with complex physical, emotional, and social vulnerabilities (unmanaged diabetes, alcoholism, grief, inadequate self-care).
He frequently requests pain medication beyond what is typical, raising concerns about overmedication.
Ethical Tension: Nurses must balance adequate pain management with the potential dangers of overmedication, especially for patients with histories of addiction, where bias can influence decision-making. Pain management needs individualized assessment, acknowledging varying thresholds for relief.
Tronto's Four Phases of Caring: Detailed Application
Tronto's framework provides a structured approach to understanding and implementing care, as demonstrated in the Mr. Jones case.
1. Caring About: Recognizing Need
Main Element: Attentiveness.
Application to Mr. Jones: Recognizing Mr. Jones’s physical and emotional suffering, including his need for increased pain medication and the underlying causes of his distress.
2. Taking Care Of: Assuming Responsibility
Main Element: Responsibility.
Application to Mr. Jones: Assuming responsibility to effectively address his pain and advocating on his behalf.
3. Caregiving: Direct Provision of Care
Main Element: Competence.
Application to Mr. Jones: Actively contacting the physician to request an adjustment to his dosage. This phase acknowledges that "facing conflict with this physician is a necessary part of care" (\text{113}).
4. Care Receiving: Evaluating the Outcome
Main Element: Responsiveness.
Application to Mr. Jones: Evaluating the success of the intervention by monitoring Mr. Jones’s response to the new medication. "This last phase helps preserve the relationship between patient and nurse, and is a distinctive aspect of the ethics of care" (\text{113}).
Tronto's Four Elements in Detail
Attentiveness:
Definition: Recognizing the needs and vulnerabilities of others, requiring one to step outside their own frame of reference to empathize with the patient's.
In Mr. Jones's Case: Involves acknowledging his physical and emotional suffering. Understanding his medical history (e.g., chronic alcoholism affecting pain response) prevents dismissing his requests for pain medication, recognizing them as potentially valid. "Attentive nurses take up a receptive position with respect to the patient; they are challenged to step out of their own personal preference system in order to take up that of the patient, so they can better understand the patient’s real-life situation" (Gastmans, \text{2006}, p. \text{136}).
Policy Examples: "No pass zone" policies and hourly rounding encourage staff attentiveness.
Responsibility:
Definition: Assuming a moral commitment to act on behalf of the care recipient.
In Mr. Jones's Case: The nurse assumes moral responsibility to advocate for better pain management, even if the physician is reluctant. This extends beyond routine obligation, demonstrating a deep commitment to alleviating his suffering.
Competence:
Definition: Possessing the necessary professional judgment, skills, and knowledge to provide effective care.
In Mr. Jones's Case: The nurse uses professional judgment and knowledge of Mr. Jones’s medical history to appropriately advocate for changes in his pain medication. Hospital administration has an obligation to provide education on pain management, and nurses have a responsibility to continuously update their competence.
Responsiveness:
Definition: Evaluating how the care delivered is received and whether it genuinely meets the recipient's needs.
In Mr. Jones's Case: After the physician adjusts the morphine dosage, the nurse continuously monitors Mr. Jones’s pain levels to ensure the intervention is effective. "The patient is vulnerable to the nurse’s actions or lack of actions. In some situations, the patient’s lack of responsiveness to analgesia is not reassessed to determine if a different plan of care is warranted. The nurse needs to verify that the caring needs of the patient are met" (\text{114}).
Rejecting a "One Size Fits All" Approach
Anti-Universalism: Care ethics aims to avoid the universalizing character of other moral theories, which often homogenize patients into groups based solely on symptoms.
Rejection of Rational Abstractions: It does this by rejecting the idea that moral decision-making must proceed from rational abstractions, especially since rationality is heavily employed in scientific contexts.
Cultivating Capacity: Care ethics encourages the development of one's capacity to care for others, rather than relying on a predetermined decision procedure.
Compassion in Medicine
Center for Compassion And Altruism Research And Education (CCARE): Stanford University's CCARE (\text{https://ccare.stanford.edu/}) studies evidence-based methods for developing compassion and preventing compassion fatigue, recognizing its importance in clinical practice.
The Context Dependence of Human Connection
Language is Glorious Chaos: Human communication is complex; words carry countless signals, contexts, and subtexts, and every listener interprets them uniquely.
Goal of Communication: The goal is not certainty, but rather to improve at guessing how words affect people to evoke desired feelings.
Intent vs. Interpretation: Example provided: Misunderstanding "I could care less" vs. "I couldn't care less" highlights how the intention (to alleviate loneliness) can be perceived differently depending on the listener's interpretation (as tips or as showing off knowledge).