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Abstract

This entry focuses on the history and development of care ethics from its ancient roots to present-day comprehensive care ethics theories. The entry of the development of care ethics includes alternative conceptual models and theories of ethics that counterbalance the dominant Western philosophical and political theories that are based on justice, independence, and rights. The entry highlights various interpretations of care and caring particularly in feminine ethics and nursing, landmark research in the psychology of moral reasoning from a care perspective ﬁrst described as a “different voice” by Gilligan in 1982, feminist interpretations of care ethics, critiques of care ethics, and examples of contemporary care ethics theory development and application of care ethics to selected global health issues.

Introduction

Care, at its most basic level, is a universal, human characteristic. Human beings rely on care as a constant throughout their lives, most notably required at birth through the vulnerable period of infancy and early childhood and during times of frailty, illness, and injury. Given the importance of care for human survival, it is remarkable how little impact care has had, until recently, in the development of ethical theory. The dominant theories in ethics have been largely based on assumptions about individualism, self-interest, justice, and rights. Bioethics in particular draws heavily on the work of Immanuel Kant (1724–1804) and his emphasis on universalizable rules and abstract principles. Perhaps care was neglected as the basis for theory development or normative guidance because it is so commonly encountered in human life as to be almost invisible. Care is associated with traditional “women’s work” and thus could be seen as less important. Finally, care might have been ignored because it is so much a part of the realm of intimate human interactions that it appears rather ill suited for the public concerns of law and politics. Yet, the present perspectives on a comprehensive care ethics attempt to take into consideration these broader social concerns, argue that a comprehensive view of morality requires care as its core, and situate justice as an appropriate alternative in speciﬁc situations rather than the source of normative guidance.

History And Development Of The Notion Of Care

Many origin myths include some notion of care, often personiﬁed in a deity who explains how care came to be part a central part of human nature. One particular Greco-Roman myth describes the role of care in the creation of human beings. One day, Care was crossing a river when she reached down and started to create a human being from the mud. She formed the human and then Jupiter came along. Care asked Jupiter to breathe life into the human, which he did. Soon after, Care and Jupiter began to argue about naming the human. Care wanted to name the new creation after herself since she made it. Jupiter said the human should bear his name since he gave it life. Then Terra (Earth) argued that the creation should be named after her because she gave her very substance to make it. Since they could not come to an agreement, they sought out the counsel of Saturn to sort out the dispute. Saturn considered the situation and made the following judgment. The creation would be called homo because it was made from the humus that is the Roman word for earth. When the human dies, its body would return to the earth from whence it came and Jupiter would receive the soul because he breathed life into the body. As for Care, Saturn entrusted her with the safekeeping of the human throughout its life since she created it (Reich 1995, p. 320). Throughout the history of the development of the idea of care and its role in human life, this foundational myth appears in several places. The myth is part of the work of Goethe (1749–1832) in his poem Faust, in the philosophical work of Heidegger (1889–1976) in Being and Time, in the work of existential psychologist Rollo May (1909–1994) in Love and Will, and in the work of contemporary moral theologian Warren Thomas Reich. All of these authors have made the idea of care central to their work and the role it plays in human life. Human beings are created by Care. Care holds and attends to the well-being of humans for their entire lives. The myth also includes rituals and understandings of what happens when people die. Many faith traditions hold that the spirit or soul of the person returns to a deity, afterlife, or reincarnation. The practice of burying the dead or returning it to the earth in some manner is also reﬂected in the Care myth. The myth would seem to direct human beings, because we are created by Care, to emulate the dedicated attention of Care to the well-being of others.

The underlying concept of care that is central to the development of moral theory has afﬁnities to other non-Western moral perspectives such as the African philosophy of Ubuntu that highlights the essential connectedness of humanity and therefore a particular formulation of an ethics of care or the Navajo Nation (Diné) belief about the central aspect of individual and community identity. Thus, by exploring these speciﬁc examples and other worldviews of care, it becomes clearer that the dominant Western philosophical and political tradition about the nature of humanity as individualistic and rationalistic may be the exception or at least different from other cultures or religious understandings that promote collective responsibility for welfare.

In general then, there are underlying characteristics of care including recognition that persons are not all situated so as to be independent and equal even if in certain situations human beings assume that this is the case in their interactions with others. Care is occupied with actual persons and their needs rather than people in general. This particular characteristic of care is problematic, because a comprehensive theory of care would seem to require a view that accounts for all types of interactions and obligations among people, not just those within intimate, personal relationships. Care involves mutuality or the ability to recognize oneself in others. Care often involves transformation in that the act of caring changes or affects not only the one cared for but the one who cares as well.

The Shift From Care To The Concept Of Caring

Philosopher, Milton Mayerhoff (1925–1979), described caring as a virtue or character trait of human beings in his book On Caring in 1971. Basically, his description of caring involved helping others grow in which the carer experiences what is cared for as separate and yet part of the carer as well (p. 1). Mayerhoff does not limit the object of care to human beings but to any type of work, project, or creative activity that requires this type of considered and careful attention for its “growth” and well-being. There are a variety of key characteristics that describe the impact of the act of caring on the “carer” and the recipient of care. According to Mayerhoff (1969), some of the major ingredients of caring include knowing in that caring requires knowledge of the other including explicit and implicit knowing and knowing facts as well as knowing how to care for the particular person or project. The importance of knowing to care is often highlighted in the work of feminine and feminist philosophers who followed Mayerhoff. Caring also includes adjusting to the changing needs of the one cared for, which also requires patience, honesty, trust, and humility (pp. 11–28). He argues that caring is instrumental in overcoming arrogance and the illusion that we are independent. Finally, he asserts that we are able to live the meaning of our lives through caring for “appropriate” others who he deﬁnes as people or projects that complete us and complement us. Appropriate others are separate yet an integral part of our lives (p. 58).

Feminine Ethics

Nel Noddings, a philosopher, developed the concept of caring into a theory of care with a distinctive feminine perspective. She based her work on considered reﬂection and analysis of mothering as a starting point for ethics.

Noddings’ (1984) theory could be seen as a virtue ethics that grows out of childhood experience of being cared for. Her work shifts the focus from principles and rules to natural sentiment. According to Noddings, speciﬁcs matter greatly in moral decisions. Principles are at best guidelines and not ﬁnal arbiters for moral action. Noddings’ ethics of caring focuses on interpersonal interactions between ethical parties often presented in terms of feelings. Her position is the caring relationship is ethically basic (p. 3). Noddings argues that genuine care presumes intimacy and immediacy that requires the carer to step out of his or her frame of reference into the cared-for’s reality. Noddings’ theory has been criticized for a variety of reasons including its reliance on feelings over thought as well as the inadequacy of the unidirectional, dependency relationship model she proposes for caring. In addition, Noddings could not or did not address how caring worked outside of intimate relationships, that is, she did not describe what the obligations are to help strangers.

It is understandable that nurses responded to the basic characteristics of caring because of the connection to the intimate, personal relationship that they hold with their patients. In an ideal world, nurses would provide physical, emotional, and spiritual care to the whole person. Nurse theorists categorized caring as a human trait, a moral imperative, an interpersonal interaction, and a therapeutic intervention to name a few. Numerous nurse theorists have proposed care oriented theories. The following individuals are among the earliest and most inﬂuential in modern conceptions of care in nursing and provide a range of perspectives.

Nursing Theories Of Caring

One of the earliest theorists in nursing in care ethics was Madeleine Leininger (1925–2012). During the 1976 American Nurses Association Convention, Drs. Madeleine Leininger and Jody Glittenberg presented a program on the subject of care as the essence of nursing. Following the presentation, Leininger noted the positive response it generated in the nursing attendees and the paucity of the nursing literature on theory development and research on caring. For these reasons, Leininger established a series of National Caring Conferences that began in 1978 that laid the groundwork for the development of nursing and other researchers’ exploration of the caring phenomena in nursing. Leininger (1979) speciﬁcally focused her research efforts on cross-cultural functions of caring that she maintains are critical factors for human growth and development as well as the survival of human cultures (p. 95). The vital act of caring for each other, she argues, leads to groups of humans banding together in recognition of their interdependence and interrelatedness. She sees caring as a “cultural mechanism” that acts as a safety valve to alleviate misery and suffering (p. 97). Caring then is therapeutic and an integral part of the healing process. She encouraged research into the humanistic aspects of caring on an individual and worldwide level. Well ahead of her time, Leininger (1979) spoke about the global implications of care on health and politics: “Caring attitudes and behaviors will be important to maintain peace, communication and daily working roles of any culture. More caring and less war threats are needed for future international health living modes” (p. 95).

Marie Simone Roach, a member of the Sisters of St. Martha, Nova Scotia, Canada, became interested in the nature of human caring early in her career as a nurse and educator. She organized caring behaviors in nursing practice into six categories: compassion, competence, conﬁdence, conscience, commitment, and comportment. She went on to explore human caring in itself and proposed a caring ontology, Caring, the Human Mode of Being (Roach 1987). As her research and reﬂection on care continued, she included spirituality as a characteristic of being human as well as deep concern for the global community and the very planet itself.

Sarah Fry, a nurse and philosopher, traces the development of nursing ethics through four concepts that comprise the moral foundation of nursing: cooperation, accountability, caring, and advocacy (Fry 1989). She notes that these four concepts are internationally accepted and shape nursing ethics. Fry describes the relationship between nurse and patient as a covenant, that is, a reciprocal promise to be faithful in providing nursing services to the patient and, in return, the patient promises to be honest and trust the nurse. Fry asks questions about the nature of nursing practice and the moral phenomena of nursing and then moves on to ask what role a theory of care should play in nurses’ ethical judgments. She claims that care promises a theoretical foundation for a nursing ethics (Fry 1989) but that considerable work needs to be done to clarify the multiple meanings of care in the nursing and related literature.

Generally, the work of nurse theorists in caring was not critically analyzed. When it was, it was noted that the claims and deﬁnitions/descriptions were somewhat vague and difﬁcult to measure in concrete terms and perhaps not as relevant to nursing as would appear so at ﬁrst glance. Some of these same criticisms have been leveled at care ethics, in general, and are addressed along with others in the section on critiques of care ethics.

Care Ethics And Moral Reasoning

Gilligan (1982) is arguably the person most responsible for identifying an alternative approach to moral questions and the underlying, unexamined assumptions that frame moral perceptions. Gilligan’s research grew out of her observations of the work of Lawrence Kohlberg (1927–1987) and Jean Piaget (1896–1980) on moral development which generally excluded female subjects and from which norms in moral reasoning were established. The higher levels of moral reasoning were characterized by invoking impartial rules or principles including reciprocity, that is, fairness or justice. She noted in her own research that women’s voices in moral development sounded distinct and proceeded to explore and interpret the voices that she notes, early on in her work, are characterized not by gender but by theme (p. 2). The different theme that Gilligan describes is one in which connection and relation to others is central. She concludes that individuals are interdependent. Thus, promoting the welfare of others or preventing harms is critical to the well-being of all. Later work and reﬂection on care ethics led Gilligan to the conclusion that traditional ethics that holds a rights-oriented, autonomous individual as the norm enforces and supports a patriarchal order that relegates care to a secondary, supporting role.

The differences between justice and care are often, inappropriately many would argue, described as polar opposites along the following lines: if the world is a place full of self-interested individuals and the best way to strike some kind of arrangement to limit this self-interest, then the need for social contracts to mediate this basic conﬂict between individuals makes sense. If the world is made up of people who are dependent and interdependent and connected in complicated webs of relationships, then some other way to look at conﬂict and resolution is needed. These distinctions between justice and care may be clear but that does not mean that they should remain opposites. At least initially, care ethicists did not consider the question of how or if care and justice could be reconciled in some manner. Rather they directed their attention to developing the care perspective and defending its legitimacy. Most of the philosophers who drew on Gilligan’s work to develop care ethics are feminists.

Feminist Interpretations Of Care Ethics

At ﬁrst glance, it would seem that care ethics would align with feminist thinkers since it appears to express women’s experiences, moral reasoning, and moral ideals. Yet, that is not always the case. The following feminist philosophers, among many others, made signiﬁcant contributions to the development of feminist care ethics.

Margaret Urban Walker (1989) describes the traditionalist view of moral thought as abstract, authoritarian, impersonal, and universalist. In contrast to this view, she summarizes two schools of thought regarding feminist ethics. The ﬁrst of these is a focus on the moral legitimacy and necessity of changes to societal, political, legal, and personal structures that sustain male domination or any form of domination (p. 15). The second view focuses on the moral perceptions and values of women so that they are represented and restored to moral discourse (p. 16). She refers to the latter as reconstructionist work and proposes an alternate epistemology based on careful consideration of the context (relationships) and concreteness (individuals involved) that are connected by an ongoing narrative. She cautions against a separatist sphere approach to ethics that assigns different moral theories for public and personal life. Rather, she argues for an interpersonal view of the moral life (p. 20). This view prioritizes giving voice and listening among those involved who are answerable in and for actual ongoing relationships.

Joan Tronto, added two important elements to accounts of care. First, she and colleague Berenice Fisher constructed a systematic deﬁnition of care. Several parts of the deﬁnition are important because they afﬁrm previous assertions in care ethics or introduce further qualiﬁcations. For example, Fisher and Tronto (1990) claim that care is a “species” activity, that is, part of human nature and evident in action, not only feelings. Second, they extended the scope of care ethics to a global level that includes human beings and the environment. The work of care then is part of private and public life and can be a vehicle for political change with its anthropology of interdependence. Fisher and Tronto (1990) propose that the process of care includes four phases: (1) caring about, (2) caring for, (3) caregiving, and (4) care receiving (p. 3). Caring about refers to the recognition that care is needed. Caring about requires an attentiveness to the needs of those we know and those we do not know personally. Caring for occurs when someone takes at least partial responsibility to respond to the need for care. Caregiving is the actual act of providing care. They note that caregiving requires cooperation for individuals to provide the necessary care. Additionally, it depends on competence since this is a fundamental requirement of effective care. Finally, care receiving closes the process by noting the effectiveness of the care on the one receiving it and links it to the responsiveness of the caregiver. Responsiveness also entails sensitivity to the inequities in power between those who offer care and those who receive it.

Criticisms of care ethics are numerous and can be categorized according to their source. The most vocal critiques were philosophers, feminists, and philosophers who held with the traditionalist, principled views of ethics, which if nothing else made interesting bedfellows in their shared skepticism of the legitimacy of care ethics.

Critiques Of Care Ethics – Feminist Perspectives

General critiques of care ethics from feminist ethicists concerned the problem of reinforcing general stereotypes of women as caregivers and existing social patterns to the detriment of women. Since women are already unfairly burdened with care obligations in the present social structure, it would be a mistake, so the argument goes, to identify care ethics with the feminine gender. The problem is one of reinforcing existing social patterns that allow continuation of oppression. Additionally, care ethics is devalued because of its association with women, they argue, and thus a poor tool to move the feminist agenda forward. It would seem at ﬁrst glance that the use of rights language would be more helpful to deconstruct inequities in power rather than care. However, counterarguments to this point emphasize that care ethics is not an ethics for women but it is an ethics for human beings and that everyone suffers when there are inequities in power and oppression (Gilligan 1982; Manning 1992).

The largely unexamined concept of the inherent good of relationships has also been noted by feminist philosophers as a topic for exploration. Are all relationships worthy of protection? If not all, then how does one judge which relationships are worth protecting? Relationships differ in degrees of intimacy and immediacy. In other words, human beings are inclined to take the needs of intimates more seriously than the needs of strangers. The internal problems with relationships led to broader questions about inclusion, a criticism raised by feminists and non-feminists alike.

For whom should human beings care? How far do responsibilities for care extend? The extent of care obligations is a problem raised by Noddings (1984) but not addressed by her. Manning (1992) notes that Noddings is correct in that care ﬂows from not only the existence of relationships but also the possibility of relationship for others not yet known. It does not follow that human beings do not have obligations to strangers, just obligations that are different from those with intimates that include special obligations. Ties of affection, loyalty, and trust should and do matter. Human beings are obligated to work for a caring world in a variety of ways not only in relationships with intimates. However, there is no consensus on the limits of care. The overwhelming need for care in the world and the ﬁnite abilities of human beings to provide all the care that is needed seems to create an unresolvable problem.

Critiques Of Care Ethics – Principlist Perspectives

Non-feminist philosophers and others have raised different types of problems with care ethics. A common criticism is the vagueness of care ethics regarding moral responsibilities. This particular criticism has been leveled at virtue ethics too claiming that morally good character traits are not sufﬁcient for moral action. Therefore, several critics of care ethics have argued that principles must remain as the central guide for moral reasoning. Personal experience, beliefs, and context are important, even essential, elements of moral reasoning but should never be the sole basis for an ethical decision. Additionally, there is a lack of clarity about the basic concepts and terminology of care ethics. Another criticism is that care relies on sentiment as a guide to moral action that, at best, is unreliable. Emotions can lead in the wrong direction without clear principles for right action. Supporters of care ethics would argue that purely emotional reactions should not be the sole source of guidance for resolving complex moral problems but that emotions are an integral part of moral intuition and reasoning. In an exploration of the place of care in ethical theory, Veatch (1998) dismisses interpretations of care as a new principle of morality, a virtue, or a virtue theory but considers the intriguing possibility that proponents of care may be opening a new branch of normative ethics that focuses on relationships.

Care ethics has evolved from a view of care and caring as a value, behavior, human trait, or virtue, to more fully formed conceptual frameworks to theories based on feminine, nurturing behaviors to feminist principles and aims. The most recent development in care ethics includes examination of how justice and care can be understood in relationship to each other. For example, are justice and care alternatives whose use is dependent on the type of moral conﬂict involved? Are care and justice complementary in that each shores up weaknesses in the other? A complementary approach could take a justice-in-care view in which justice is applied to relationships, at whatever level, so that all relationships remain just in care ethics. This sort of application would work against the problems with partiality that could lead to, at a minimum, parochialism and at the extreme to racism (Van Stichel 2014, p. 500).

Contemporary Theory Development And Applications Of Care Ethics

Others have offered broader applications of care ethics on a global basis with concepts such as empathy as an organizing concept for moral reasoning in which rights-based, justice language is not sufﬁcient. For example, Slote (2007), a moral philosopher, views an attitude of empathic caring as the central focus of his version of an ethics of care. He emphasizes that empathy is critical to moral motivation (p. 125). In his theory development, actions are considered good insofar as they reﬂect or exhibit an appropriate amount of an attitude of empathic caring and wrong if they reﬂect or exhibit a lack. He attempts to broaden the scope of care ethics from interpersonal relationships to those we do not know by examining the concepts of immediacy and distance (p. 21). Psychological research supports that children generally have an innate capacity for empathy particularly for those who are closer to them physically and emotionally. As children develop, this basic empathic attitude develops along with cognitive abilities that could lead, he argues, for a systematic account of moral education. He also notes throughout his work that an attitude of empathic caring usually aligns with moral intuitions. He attempts to explain how his theory deals with respect for autonomy and social and distributive justice that often fall outside theories of care. However, he acknowledges problems with partiality for caring more for people who are similar and concerns about the impact of conditioning emotional reactions in a certain direction. He disagrees strongly with other care ethicists who attempt to harmonize justice and rights with care ethics (p. 129).

In addition to the work of individual scholars, there are also efforts for collaborative work by scholars in different disciplines and academic institutions as evidenced by an initiative in the Netherlands in the area of ethics of care (http:// ethicsofcare.org). The common area of interest is the ethics of care and led to the establishment of a chair in the ethics of care at Tilburg University and the University of Humanistic Studies at Utrecht. In addition, there is a research group, conference, and publications.

There is also heightened awareness of the utility of care ethics in framing and analyzing global health issues. Two examples of global issues highlight the movement of people, products, information, and other goods and services across international borders and the challenges these kinds of health issues pose to traditional, justice approaches to ethics. For example, the practice of globalized commercial surrogacy or contract pregnancies between wealthy parents-to-be in ﬁrst world countries and poor surrogates in the developing world clearly involve legal issues. However, even if the legal issues are adequately addressed, there remain issues about the deeply intimate, caring relationships among the parties involved including the most vulnerable of all, the child. Another growing global health issue is the migration of educated health professionals from developing countries to afﬂuent countries which raises issues not only of the rights of individuals to seek work where they choose but of global sustainability regarding the health-care needs of developing countries. These types of global health issues could easily be framed within a justice perspective but problems of care remain. When care ethics is applied, we must pay attention to resolving the conﬂict without damage to continuing relationships and acknowledge the interdependency of ﬁrst world and developing world communities.

Conclusion

Care ethics provides insights into how human beings should view moral decisions in intimate relationships in a way that traditional principles cannot. Care ethics also turns moral attention to the particulars of a situation that matter in human interactions. Care ethics holds that moral problems must be viewed in light of the interconnectedness of human existence – with other human beings and all living creatures on the planet. Care ethics requires moral reasoning that includes attention to accommodating the needs of the self and of others and balancing the inclination for competition with cooperation. Contemporary developments in care ethics focus on the adequacy of the theory, the reconciliation of care and justice, and the normative meaning of relationships.

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