Challenging the Conception of Care in Nursing

by Dr. David L. Perry

(Reprinted with permission from Hastings Center Report 28/5, September-October 1998.)

Helga Kuhse's recent book, Caring: Nurses, Women and Ethics (Maldon, MA: Blackwell, 1997; 296+xii pp.), is a welcome contribution to the literature in nursing and medical ethics. The author provides an enlightening historical account of nurses' subservience to physicians, which even today discourages nurses from exercising independent ethical judgment. She offers a clear-headed analysis of the moral quandaries facing nurses when ordered by physicians to act in ways detrimental to patients' interests. And, centrally, she engages in a penetrating examination of the "ethics of care," exposing a number of serious conceptual mistakes on the part of its proponents, and criticizing ways in which it has been appropriated uncritically by many contemporary writers in nursing ethics.

Kuhse's analysis is careful and sophisticated but nonetheless highly engaging and quite accessible to non-philosophers. Her book deserves to be read and discussed not only by nurses, to whom it seems most directly addressed, but also by physicians, bioethicists, and lay members of hospital ethics committees. It is well-suited for many introductory courses in health care ethics since it presumes no prior knowledge of moral philosophy and incorporates a useful primer on deontological, consequentialist, and virtue-based theories and on some weaknesses of relativism and subjectivism.

Kuhse's paramount concern is to understand how nurses, chiefly women, do and ought to think about the moral issues they face. Weighing in on the extensive debate surrounding Carol Gilligan's research in moral development and the question of whether moral reasoning is fundamentally "gendered," Kuhse sides with writers like Nel Noddings, Sara Ruddick, Caroline Whitbeck and Virginia Held, who advance the empirical claim that statistically significant differences between men and women in their focus on justice and care, respectively, are better explained in terms of "nurture" rather than "nature." Ethics may well be "gendered" to some extent, the author surmises, but it is a mistake to infer biological roots for that differentiation when social factors are sufficient to account for it (pp. 105-12).

Kuhse also recounts the historical shift from the normative metaphors of nurses as "substitute mothers" and "obedient soldiers" to the contemporary view of them as advocates on behalf of patients' rights and well-being. Moving from descriptive to normative mode, she then challenges the argument of Lisa Newton and others that nurses ought to be subservient rather than autonomous (pp. 41-60). Among its many drawbacks, that stance has too often encouraged nurses to remain silent even when confronted with gross abuses of patient rights (pp. 34-35, 204-5). But Kuhse is also critical of recent claims that care-related virtues can by themselves fulfill the principle of patient advocacy.

The author acknowledges that recent discussions of "care" have at least exposed the lack of attention given by some traditional justice-based approaches to many morally significant issues now being raised by nurses and women. But against an exclusive focus on care in nursing ethics, she also contends that "no adequate ethics can do without universal principles and justice." Those attempting to do so "constitute, at best, an inadequate ethics and, at worst, a dangerous one. In not allowing the articulation of principled claims, these care approaches facilitate the continued exclusion of nurses from ethical discourse and are unlikely to serve either nurses or patients well" (p. 11).

Noddings, a proponent of a care orientation whose ideas have influenced many writers in nursing ethics, has attacked principle- and rule-based ethics for being abstract rather than concrete. Kuhse recognizes that practical ethics can never be done in isolation from particular circumstances: "Without reference to such facts, it would be impossible to determine whether a relevant act infringes the principle or rule in question." In fact, the author begins her book with compelling stories about two nurses and their terminally ill patients, and she cites them at many subsequent points to illustrate her arguments. However, drawing upon critiques of Noddings by Claudia Card and Laura Purdy, Kuhse points out that Noddings' own approach must inevitably "abstract some details from the infinite number that form the backdrop to a given situation. . . . This means that the central question is not whether context is relevant, but rather which elements of a particular context ought to be 'abstracted' from the overall context as significant for ethical decision-making" (pp. 120-21).

In addition, Noddings' rejection of universalizability in favor of special responsibilities generated by unique relationships between persons rests on "a confusion between particular individuals having duties and the universality of such duties":

The principle that a son has an obligation to do certain things for his mother, or that someone who has made a promise should keep it, is not specific to a particular individual; rather, it holds for all individuals who find themselves in the relevant circumstances or relationships (p. 125).

"Partialist" approaches to ethics like that of Noddings are too narrow in scope in other respects as well:

Not all our actions affect individuals with whom we stand in personal relationships. This is the case, for example, when a hospital administrator determines the criteria for admission to the hospital's dialysis program. . . . This means that unless exponents of a personal ethics of care wanted to take the hard-nosed view that we never have any moral duties and responsibilities to those with whom we have no personal relationships, they would still need to devise and defend some ethical principles to govern our relationship with strangers. . . . An adequate ethics needs impartiality as well as care (pp. 137-38).

Kuhse also finds Noddings' ideal of care as "engrossment" to be inappropriate in the nursing context. Echoing Stan van Hooft, Kuhse contends that the level of intimacy advocated by Noddings may not only be unattainable in many nurse-patient interactions (and thus an ultimately frustrating objective for nurses) but may also not be in the best interests of patients themselves:

It seems highly unlikely that every patient who enters hospital with a particular medical problem . . . would want the many different nurses who look after her during her hospitalization to make serious efforts to "enter into her life space" or to form an engrossing relationship of the "I-Thou" kind. Rather, what such patients are much more likely to want is to have their health-care needs competently and professionally attended to by a responsive and sympathetic nurse (p. 149).

On the other hand, Kuhse believes that nurses quite properly attend to the anxiety, pain and frustration that patients typically experience along with their illnesses. She advocates what she terms "dispositional care," meaning "a willingness and openness to apprehend the health-related reality of the other," recognizing patients as "particular others" having special needs, beliefs and desires. This approach can also serve as a useful corrective to a tendency under the "medical model" to treat patients predominantly as "malfunctioning organisms" (p. 150).

But again for Kuhse, care must not be isolated from principles of impartiality and justice. Indeed, she believes that care properly construed is often quite compatible with a principle of respect for persons as rational agents:

In valuing autonomy and caring about a patient's interest in self-determination . . . we are also showing care and concern for her as a relational being, that is, for her own particular understanding of relationships and of existing ties of love and affection. One person may wish to undergo chemotherapy, for example, to increase her chances of seeing her first grandchild being born; another may wish to reject life-extending treatments, to spare herself and her loved ones a slow and drawn-out dying process. In other words, I am suggesting that one of the best ways of caring for people is to respect their autonomy and their rights (p. 174).

Indeed, Kuhse proposes that in caring for the dying, nurses should be accorded greater professional authority not only to prescribe palliative treatments but also to write DNR orders and to facilitate voluntary suicide and active euthanasia. And she urges professional nursing associations to end their official opposition to the latter options in order more fully to uphold in practice what they have affirmed in writing--patient autonomy and dignity (pp. 207-19).

The nursing profession will never again promote subservience as its ruling ethical principle. But it ought now to abandon some misguided models of "care" that it has uncritically absorbed ostensibly in the name of patient advocacy. Helga Kuhse's important book provides a robust alternative to those inadequate approaches.

Copyright 1998 The Hastings Center. Reprinted by permission. This article originally appeared in the Hastings Center Report vol. 28, no. 5, September-October 1998. The Hastings Center Report is sent six times a year to members of The Hastings Center. For information regarding membership, please be in touch with Membership Department, The Hastings Center, Route 9D, Garrison, NY 10524; phone (914)424-4040; fax (914)424-4931.

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