Care Ethics and Nursing Practice

Abstract

Care ethics, also known as ethics of care, is one lens with which to view ethics as applied to nursing and care more generally. The beginning of this particular approach to ethics as applied to care is attributed to the work of Carol Gilligan and Nel Noddings in the early 1980s. Care ethics has evolved primarily in North America and Europe with different strands and input from philosophers and social scientists. This chapter traces the development of care ethics, summarises key elements and focuses on the work of two theorists – Joan Tronto and Chris Gastmans – and the implications for nursing ethics. A short case study from an ethics education research project suggests the value of applying insights from care ethics to everyday practice situations. The strengths and limitations of care ethics are discussed and it will be concluded that, whilst care ethics makes a valuable contribution to ethics as applied to care, other perspectives enhance this approach.

Introduction

There has been scholarship on ethics as applied to care since the 1800s. Marsha Fowler (2016) points out that, from 1890 to the 1960s, approximately 50 texts were published on nursing ethics. Many of these were written by nurses but some were authored by social workers, priests or physicians. The topics within these texts are still relevant today, with discussions of confidentiality, truth-telling, the atmosphere of the hospital (what we would now refer to as ethical climate) and duties towards patients, the family, the doctor, towards the nurse herself, her friends, her hospital and school, and other nurses. Fowler argues that early nursing ethics:

…effectively removes nursing’s ethics from the realm of a “bedside ethics” alone to one that reaches into both the problems of society and the structure of society. These early requirements are the precursors to contemporary nurses’ concern for health disparities. However, an examination of these historical requirements in social-ethical and social justice content, as well as the nursing ethics historical literature, indicates that nursing’s perspectives on social justice do not align very well with the bioethical discourse on distributive justice and are far closer in spirit to the contemporary work by, Baier, Held, Kittay and colleagues […] Tronto and others who look closely at structural inequalities far more broadly than concerns for the costs and access to healthcare. (Fowler 2016 p. 11)

Baier, Held, Kittay and Tronto are but some of the leading theorists who have contributed to a particular approach to ethics as applied to care. This has become known as both ‘care ethics’ and ‘ethics of care’. This one approach albeit with different varieties by different authors – primarily in Europe and the United States – emphasises the primacy of relationships of care. It is presented as remedying some of the deficits of bioethical approaches that focus on justice, principles and professional detachment. It is, however, but one lens that illuminates ethical aspects of nursing and care practices more broadly.

In this chapter, I will provide an overview of the evolution of care ethics and an explanation of the ‘core’ elements of care ethics. I will discuss the implications of the work of two care ethics theorists – Joan Tronto and Chris Gastmans – for nursing practice and consider the potential of care ethics to throw light on ethical aspects of a care situation. I will conclude by summarising some of the strengths and limitations of care ethics.

The Evolution of Care Ethics

The beginning of care ethics is generally attributed to the publication of Carol Gilligan’s book In a Different Voice: Psychological Theory and Women’s Development in 1982. Whilst early writings from nurse scholars and from feminist and other philosophers (for example, Mayeroff 1971) had features of care ethics, it was Gilligan’s work that is credited with initiating the particular approach which has become known as both ‘care ethics’ and ‘ethics of care’. Around the same time, Nel Noddings published Caring: A Feminine Approach to Ethics (1984) which had much in common with the themes identified by Gilligan and later care ethicists. Michael Slote (2007 p. 10) has argued that it was Noddings, rather than Gilligan, who ‘was the first person to attempt to spell out an ethics of care’. Nevertheless, it is Gilligan who is most often referred to as the originator and her research is most illuminating as background to the approach.

Gilligan’s research challenged some of the findings of earlier work by American psychologist Lawrence Kohlberg and his perspective on stages of moral development. She reports findings from the presentation of a dilemma, devised by Kohlberg, to two 11 year old children, Jake and Amy. Gilligan (1982 p. 25–26) describes the situation as follows:

The dilemma that these eleven-year-olds were asked to resolve was one of a series devised by Kohlberg to measure moral development in adolescence by presenting a conflict between moral norms and exploring the logic of its resolution. In this particular dilemma, a man named Heinz considers whether or not to steal a drug which he cannot afford in order to save the life of his wife. In the standard format of Kohlberg’s interviewing procedure, the description of the dilemma itself – Heinz’s predicament, the wife’s disease, the druggist’s refusal to lower his price – is followed by the question, “Should Heinz steal the drug?” The reasons for and against stealing are then explored through a series of questions that vary and extend the parameters of the dilemma in a way designed to reveal the underlying structure of moral thought.

Gilligan explains how Jake proceeds to respond logically as he sees the problem as “sort of like a math problem with humans” (p. 26). He constructs the problem as one of a conflict between ‘the values of property and life’ and concludes that Heinz should steal the drug. Jake was of a view that a judge “should give Heinz the lightest possible sentence”. Amy, on the other hand, responded to the dilemma differently and appeared uncertain. She didn’t think Heinz should steal the drug and wanted to explore other options, for example, borrowing the money for the drug or taking out a loan. She was mindful of the effect of a theft:

If he stole the drug, he might save his wife then, but if he did, he might have to go to jail, and then his wife might get sicker again, and he couldn’t get more of the drug, and it might not be good. So, they should really talk about it and find some other way to make the money (p. 28).

Gilligan points out that, unlike Jake, Amy does not see the dilemma as a maths problem but rather as ‘a network of connection, a web of relationships that is sustained by a process of communication’ (p. 32). Gilligan’s analysis of the response highlights well the distinction between ethics as underpinned by logic and law and a ‘different voice’ of care:

Instead, seeing a world comprised of relationships rather than of people standing alone, a world that coheres through human connection rather than through systems of rules, she finds the puzzle in the dilemma to lie in the failure of the druggist to respond to the wife. Saying “it is not right for someone to die when their life could be saved”, she assumes that if the druggist were to see the consequences of his refusal to lower his price, he would realise that “he should give it to the wife and then have the husband pay back the money later”. Thus she considers the solution to the dilemma to lie in making the wife’s condition more salient to the druggist or, that failing, in appealing to others who are in a position to help (p. 29).

Many examples discussed in Gilligan’s text illustrate different ways of thinking about ethics. She writes (p. 173):

My research suggests that men and women may speak different languages that they assume are the same, using similar words to encode disparate experiences of self and social relationships […] may contain a propensity for systematic mistranslation, creating misunderstanding which impede communication and limit the potential for cooperation and care in relationships. At the same time, however, these languages articulate with one another in critical ways. Just as the language of responsibilities provides a weblike imagery of relationships to replace a hierarchical ordering that dissolves with the coming of equality, so the language of rights underlines the importance of including in the network of care not only the other but also the self.

We arrive at two distinct ethical perspectives set out in the conclusion to Gilligan’s 1982 text (p. 174). It is worth quoting in full as this underpins much of the later development of care ethics:

To understand how the tension between responsibilities and rights sustains the dialectic of human development is to see the integrity of two disparate modes of experience that are in the end connected. While an ethic of justice proceeds from the premise of equality – that everyone should be treated the same – an ethic of care rests on the premise of nonviolence – that no one should be hurt. In the representation of maturity, both perspectives converge in the realization that just as inequality adversely affects both partners in an unequal relationship, so too violence is destructive for everyone involved. This dialogue between fairness and care not only provides a better understanding of relations between the sexes but also gives rise to a more comprehensive portrayal of adult work and family relationships.

Gilligan’s early research and conclusions regarding two different approaches to ethics and moral development continue to be very influential. However, limitations of her research have also been highlighted. Joan Tronto (1993), for example, points out that Gilligan’s work does not challenge the boundary between private and public life and between justice and caring. An undesirable consequence is that relegating caring to private life it is considered to be outside the political realm and not considered as part of public life. Tronto argues that the work of Gilligan – and also that of Kohlberg – ‘maintain the position of the relatively privileged’ (p. 96) whereas valuing care should be considered as both a moral and a political process.

Theories strengthening the idea that the ethics of care is a defensible alternative to an ethics of justice – or should be combined – have been developed by philosophers and feminists such as Joan Tronto (1991 with Fisher, 1993, 2013), Virginia Held (1993, 2006), Eva Feder Kittay (1999, 2002) and Sara Ruddick (1989). In relation to nursing care specifically, ethicists such as Chris Gastmans, Per Norvedt and Helen Kohlen continue to develop this approach. It is not possible to do justice to the work of all of these care ethicists so I focus on two. Before discussing the contribution of Joan Tronto and Chris Gastmans – with reference to an aspect of Kittay’s work – elements of care ethics will be discussed.

The Core of Care Ethics

There is much diversity in care ethics and many rich perspectives continue to be developed. It is difficult to determine exactly what is agreed as constituting the approach. Political theorist, Stephanie Collins (2015), helpfully sets out a care ‘slogan’ and four claims. The slogan is ‘dependency relationships generate responsibilities’. The four claims which, Collins argues, ‘capture what is distinctive about care ethics’ are detailed below with some suggestions as to how they relate to care practices and to other approaches to applied ethics:

Claim 1

‘Ethical theory should positively endorse deliberation involving sympathy and direct attendance to concrete particulars’ – This claim suggests a requirement fulfilled by most ethical perspectives with potential application to care practices. It seems unimaginable that an ethical theory could be worthy of consideration that accommodated unsympathetic and inattentiveness to concrete particulars. Ethical approaches that accommodate human sympathy and an emotional component of the moral life, such as virtue ethics, will also satisfy this claim.

Claim 2

‘To the extent that they have value to the individuals involved, relationships ought to be (a) treated as moral paradigms,¹ (b) valued, preserved or promoted (as appropriate to the circumstance at hand) and (c) acknowledged as giving rise to weighty duties’² – The relational focus of care ethics is different to most other ethical approaches. It is not, for example, a focus of the four principles approach or utilitarianism. However, it is a key feature of ‘relational ethics’ (Pollard 2015; Austin 2006).

Claim 3

‘Care ethics sometimes call for agents to have caring attitudes, that is, attitudes that: (i) have as their object something that has interests, or something that might affect something that has interests; and that (ii) are a positive response (e.g. promoting, respecting, revering) to those interests; and that (iii) lead the agent’s affects, desires, decisions, attention, and so on to be influenced by how the agent believes things are going with the interest-bearer’. – Care ethics in the context of care practices always calls for agents to have caring attitudes that focus on a positive response to the interests of others. This is an element that is, arguably, shared with virtue ethics³ whereby the virtue of care is a moral disposition that contributes to the flourishing of the care recipient and the care giver (Banks and Gallagher 2009).

Claim 4

‘Care ethics calls for agents to perform actions (i) that are performed under the (perhaps tacit) intention of fulfilling (or going some way to fulfilling) interest/s that the agent perceives some moral person (the recipient) to have; (ii) where the strength of the demand is a complex function of the value of the intention, the likelihood that the actions will fulfil the interest, and the extent to which the interest is appropriately described as ‘a need.’ – Responses to the needs of others, particularly those who are considered most vulnerable and dependent, is a central feature of care ethics and has to be, arguably, the focus of any ethical perspective applied to care. Approaches to ethics that can be described as teleological, with a telos or end in mind, have some similarities although the nature of the end aspired to will differ. In care ethics, Collins refers to interests and need. In utilitarianism, the end aspired to is happiness or the good of the majority.⁴ In virtue ethics, the end aspired to is human flourishing (Banks and Gallagher 2009).

Collins goes on to argue that, whilst the four claims capture the distinctiveness of care ethics, they require an overall unifying principle. This is described as ‘the Dependency Principle’ which has four components: ‘there is an important interest that is unfulfilled; an agent is sufficiently capable of fulfilling that interest; the agent’s most efficacious measure is not too costly; and […] the agent’s fulfilling the interest would be the least costly of any agent’s doing so’ (p. 97).

The four claims as outlined by Collins present the core features of, and ethical justification for, care ethics. They can also be more fully fleshed out when considered in relation to the Dependency Principle (See Collins 2015 Chap. 8). However, they are somewhat elusive as normative prescriptions for everyday care practice and are not so clearly distinct from other approaches to ethics as applied to care. There are clearly similarities with virtue ethics and relational ethics, for example, and differences with autonomy-focused approaches to ethics. What is particularly valuable about care ethics is the recognition that care is crucially important and that any analysis of care requires both ethical and political insights. One of the most important care ethicists, Joan Tronto, brings her moral and political expertise to bear on care sharing insights and implications for individuals, organisations and global communities.

Perspectives on Care Ethics: Joan Tronto

The year 2013 marked the 20th anniversary of Joan Tronto’s 1993 text Moral Boundaries. Many of the features of Tronto’s version of care ethics have direct and obvious implications for nursing and other care practices and have been discussed elsewhere, for example, in a text marking the 20th anniversary of Moral Boundaries (Gallagher 2014). Three features of Tronto’s work are discussed here: her description of the phases of care and the ethical attitudes that accompany them; her discussion of the role of care and caregivers; and an explanation for unethical practice. First, lets look at the definition of “care” proposed by Tronto and Fisher (1991 p. 40):

On the most general level, we suggest that caring be viewed as a species activity that includes everything that 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, ourselves, and our environment, all of which we seek to interweave in a complex, life-sustaining web.

Tronto (1993) points out that their definition intentionally highlights that caring includes caring for objects that are not human; that it is not restricted to individuals or ‘dyads’ but rather should be thought of as part of wider social networks; that it is ‘defined culturally’; and that it is ongoing. Tronto (1993 Chap. 4) outlines the four phases of care and the ethical attitude that accompanies each (Table 5.1).

Table 5.1 Tronto’s dimensions or phases of care

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.

A Practice Situation – Case Study

The following is an example from focus group data relating to a care situation from a research project which evaluated three different approaches to ethics education for residential care givers (Gallagher et al. 2016, Gallagher and Cox 2015). The residential care-givers assumed the role of care recipients and care was delivered by student nurses. The context was a meal time where a care-recipient attempted to eat a slice of cheesecake with the use of one hand:

I just kept picking up that whole entire thing where it was quite sticky and really gooey and it’s cheesecake, I just want to plough in. And I just couldn’t get anything. And before I’d realised it, her hand had just come across the table, she hadn’t even looked at me, and she was just like that, and she just carried on talking. And just from that simple movement I was able to feed myself my cheesecake. And that was brilliant because there was no ‘Oh do you want any help with that?’ it was just a gentle little … yeah, to make it blatant to everyone … it was just a little slide of a hand, place the fingers on it and just carried on talking … nobody … I didn’t actually even notice that she’d done it until I’d actually finished. [RIPE project Focus group 5]

The student nurse care-giver shared her view of the same situation:

I didn’t want to take away her ability to eat the cheesecake, cos I could have gone ‘Give me the cheesecake, I’ll help you’ or you know ‘Let me spoon it …’ I wanted to enable [care recipient] to eat her cheesecake herself, you know she had the ability to do it with her good hand. And I thought it would empower you more to eat the cheesecake herself and just have this ever so slight intervention. [Focus group 5]

These two extracts provide an example of a care giver assessing what the care recipient needed and acting in a way that she thought empowering. The care giver acted spontaneously and non-verbally in response to a perceived need. From a care ethics point of view, it could be argued that the student care-giver was sensitive to the vulnerability of the care recipient and to the potential for indignity. As the care recipient suggested, her deficit was not made public and attention was not drawn to it which could lead to a loss of dignity. In terms of the relevance of other care ethics concepts and dimensions, we might draw on Tronto’s four phases of care, focusing on care giving and care receiving and the associated ‘attitudes’ of competence and responsiveness.

In terms of the six dimensions of good care outlined by Gastmans et al. (1998), the physical, relational, and moral appear most pertinent. They point out that the provision of care to maintain and improve the patient’s physical condition is an essential part of good care. They discuss the serving of meals explicitly:

Having a meal is more than the functional consumption of food for purely physical ends. The serving of meals in a health care institution is, in our opinion, a very important case in point that must be elevated above its merely nutritional function in order to maintain its human character […]. By approaching the patient’s body in a prudent and respectful way, nurses can bear witness to their own striving toward care and human dignity (p. 60).

The example also relates to the relational dimension where space needs to be made for the development of a caring relationship. As meals are taken, as in this case in a social context, there needs to be sensitivity as to how the intervention will be perceived by other care recipients. A subtle, non-verbal intervention appears attuned to the needs of the care recipient. As this example comes from a simulated care ethics education intervention, there may be a question of authenticity of the experience. However, both care recipient and care giver were able to articulate the impact of the example as ‘good care’. Concepts, then, such as vulnerability, dignity, care, competence, relationality, and responsiveness appear to be applicable to this simulated practice example and resonate strongly with the care ethics literature. If this were to be considered through another ethical lens, different concepts may be considered, for example, the four principles’ approach (Beauchamp and Childress 2013). The focus would then perhaps have been on respect for autonomy, weighing benefits with potential harms and justice. If we were to draw on a virtue ethics approach, virtues in addition to care could be considered such as prudence, respectfulness and kindness.

Care Ethics and Nursing Ethics: Strengths and Limitations

The strengths of care ethics in relation to care practices seem obvious as it addresses fundamental ethical aspects of care. It is difficult to imagine how ethical discourse relating to care could proceed without reference to vulnerability, dignity, receptivity and the concept and value of care itself. However, challenging aspects of the approach have also been discussed. Maureen Sander-Staudt (n.d.), for example, suggests six potential criticisms of care ethics: that it is a ‘slave morality’; that it is empirically flawed; that it is ‘theoretically indistinct’; that it is parochial; that it is essentialist; and that it is ambiguous.

• Care ethics as a ‘slave morality’ – Sander-Staudt advises that the term ‘slave morality’ is attributed to the philosopher Nietzsche who argued that people who are oppressed tend to ‘develop moral theories that reaffirm subservient traits as virtues’. The view that care ethics supports the oppression of women is deserving of further attention. As Sander-Staudt states: ‘This objection further implies that the voice of care may not be an authentic or empowering expression, but a product of false consciousness that equates moral maturity with self-sacrifice and self-effacement.’

• Care ethics as empirically flawed – This critique focuses on the robustness of Gilligan’s research. It is alleged that her sample is too narrow and homogenous.

• Care ethics as theoretically indistinct – It has been argued that care ethics is not clearly distinct from other ethical approaches and shares many of the same values, for example, equality, autonomy and justice. It has particular similarities with virtue ethics particularly when care is construed as a virtue.

• Care ethics as parochial – This criticism stems particularly from claims by Nel Noddings that care obligations were primarily to those who are close rather than to distant people. There is a concern that ‘without a broader sense of justice, care ethics may allow for cronyism and favouritism toward one’s family and friends.

• Care ethics as essentialist – There is criticism of a tendency within care ethics to focus on a ‘dyadic model of a (care-giving) mother and a (care-receiving) child, on the grounds that it overly romanticizes motherhood and does not adequately represent the vast experiences of individuals’. Differences within gender groups tend to be overlooked and the complexity of sexual identity and sexual orientation downplayed. Black and lesbian women, for example, are likely to be different to white heterosexual women. Recent discussions of the relationship between care ethics and ‘intersectionality’ (Ward 2015) engages constructively with this criticism.

• Care ethics as ambiguous – The accusation of ambiguity stems from the view that care ethics does not provide concrete guidance on what to do. In response to this criticism, Sander-Staudt points to a range of principles that are central to care ethics relating to, for example, the origin and fundamental need for care, the nature of care relations and the ‘scope of care distribution’.

Conclusion

Care ethics or ethics of care is an approach to ethics in care that continues to evolve with contributions from philosophers and social scientists. Although some theorists have chosen to focus on the gendered aspect of care ethics, most do not. Increasingly there is also a recognition that embracing care does not exclude a commitment to justice and that care needs to be considered in the public as well as in the private domains, hence an emphasis on both the moral and political underpinnings of care. The four phases of care and accompanying attitudes identified by Joan Tronto and her discussion of the role of care givers and explanations for unethical practice (along with Kittay 2002) provide helpful insights. Chris Gastmans’ discussion of ‘good care’ and ‘dignity-enhancing care’ can also be applied to everyday care situations. The six criticisms of care ethics discussed by Sander-Staudt (undated) need to be kept under review as the approach evolves.

As care ethics is currently an umbrella for a disparate range of theoretical accounts, it seems unlikely that it will replace well-established approaches such as the four principles’ approach, deontology, utilitarianism, rights-based ethics or virtue ethics. However, it is hoped that this chapter illustrates the richness of the concepts and elements that contribute to an understanding of ‘good care’.

Key Learning Points

• There has been scholarship relating to ethics and care, most particularly nursing, since the mid-1800s.

• The beginning of ‘care ethics’ – also known as ‘ethics of care’ – is attributed to the work of Carol Gilligan and Nel Noddings in the early 1980s.

• The scholarship of Joan Tronto and Chris Gastmans has been highlighted as providing helpful insights that illuminate ethical aspects of everyday care.

• Six criticism of care ethics, as presented by Sander-Staudt (undated), should be reflected on and discussed by all who consider the potential of care ethics as an effective applied ethics for everyday care.

• At this point, care ethics should not be considered as an alternative to other approaches to applied ethics in care but rather be seen as a rich approach that challenges more individualistic, gendered and apolitical approaches.

• Care ethics continues to evolve and is likely to continue to contribute to our understanding of ethical and political dimensions of good care over the longer term.