RESPECTFUL CARE

Written by Darlei Dall’Agnol [1]

Professor of Ethics at the Federal University of Santa Catarina, Brasil

 

We humans are, as social beings, care-dependent creatures. Since the very moment we are born (or even before), we need all sorts of attention to meet our basic needs: we must be fed, clothed, sheltered, protected from many kinds of harm and so on. As infants, we need to learn how to become ordinary humans by walking, talking, socializing, etc. all activities mastered –or not– by training and other forms of educational care. Even as adults, as autonomous agents, we need constantly to look after ourselves, so self-care plays a vital role throughout our entire existences. Later in life, most of us, might become vulnerable again and will need to be cared for once more.

Caring may, however, go wrong in many different ways. For one thing, it may be insufficient to attend the basic needs of the cared-for. Thus, it may turn into negligence or even malpractice of the one “caring”. Moreover, it may degenerate into forms of paternalism when the person looking after another imposes her own views on a vulnerable individual, for example, a parent or a teacher on a teenager learning how to be independent; a doctor or a nurse on a patient in need of medical attention; a scientist on a subject of research etc. This is indeed disrespectful to the cared-for. Besides, caring may reveal anxiety, that is, it sometimes may be accompanied by negative feelings compromising the well-being of the one-caring. Then, an important question arises: under which conditions can we say that a person knows-how to care properly?

To start to answer this question, consider a real life case re-discussed in the news recently:

Baby X was born on March 1, 2009 at the midwife-led maternity unity Y, in the UK. Two weeks before, the mother complained that her baby was not moving as much. She also said that she was feeling unwell. She was checked up, but nothing was identified. There is no evidence, however, that any risk assessment took place. At this point, it would have been normal for care professionals to discuss whether she should continue with the plan to give birth at a midwife-led unit. When the baby was born, she was cold and floppy and needed medical attention, yet the midwife placed her into a cold cot. It was only after two hours that an ambulance was called. She was transferred to a hospital to be reviewed by a paediatrician. It was later revealed that Baby X had suffered from anaemia caused by a substantial fetomaternal haemorrahage. Baby X would have a chance of living if she was delivered in a hospital where she could have a blood transfusion. Consequently, she died an avoidable death.

These are the basic facts of the case. Some ethical questions are: did Baby X receive the care she was entitled too? If not, is this not disrespectful to her as a human being? How may one deliver the proper care Baby X is entitled to?

We are still far from having a clear understanding on what respectful care requires. This is perhaps one reason why some of our practices may go wrong and we fail to deliver proper care as the above case clearly shows. I hope here to make a small contribution to this topic by calling attention to some elements we need to consider in order to build up this new bioethical concept, namely that of respectful care.

There is little doubt that Baby X should not have been delivered at a midwife unit. True care needs not only good intentions or nice feelings, but also real conditions to benefit a vulnerable individual at risk of losing her life. The attention needed to improve a patient’s well-being, to restore her health or simply to protect her from further harms must be accompanied by effective knowledge, both scientifically and morally speaking, and by material conditions. There are many mistakes that care is subjected to. Technical errors, for instance in diagnosis, are not the only ones that may occur. Moral failure may also be the case. I will, however, focus here on how caring may be an expression of a special kind of moral knowledge.

As it was pointed out by many care theorists, caring is an attitude that involves knowing-how, not only knowing-that. Caring is not just a question of having justified true beliefs, but requires the effective capacity of following some normative standards. Practices such as playing chess, diagnosing diseases, etc. require the development of relevant skills. In the same way, acting morally requires acquiring knowing-how, for instance, to care for a vulnerable individual for her own sake. Moral discernment is a virtue embodied in practical knowledge. Thus, it is mastered by training in order to develop the necessary capabilities to benefit a person’s well-being and not with informational knowledge only. Moral training consists in teaching normative standards by given examples, inculcating rules and principles, punishing wrong doings etc., so that the apprentice internalizes them up to the point they are part of her own character. Moral education involves also learning-how to respond appropriately to the special value persons have. Only then one knows-how to act morally and will develop the relevant moral attitudes.

Moral sentiments such as sympathetic concern are also a condition to proper care. Sympathy is just a natural sharing of feelings and emotions, both negative and positive, any social animal has. It is immediate and involuntary rising out of our intersubjective interactions. In the human case, it is sometimes accompanied by empathy, that is, by imaginatively placing oneself in another person’s shoes simulating how she feels. They are certainly essential for proper caring, but sympathy and empathy may not be sufficient. Moreover, feelings are sometimes misleading and may even compromise proper care. If one allows oneself to be guided just by anxiety, one may end up acting wrongly. Thus, empathy must be tempered with reflection on what is really best to benefit the patient’s well-being, for instance, to effectively improve her health. Recalling the case mentioned above, midwives were probably very sensitive, but perhaps lacked the material conditions to effectively benefit Baby X’s well-being.

There is another necessary ingredient for proper care. Apart from sentiments such as sympathetic concern and empathy, the recognition of the patient as a person is essential. Without making a detailed analysis of what a person is here, let us assume that, among other things, a person is a bearer of rights and/or obligations. Thus, a patient has not only the basic right to health assistance, but other rights as well such as to give informed consent, to call for a second opinion, to have her privacy protected etc. To respect a person is not only to fulfill our obligations regarding improving health, but to be careful not violating other rights too. Consequently, it seems clear that in the case of Baby X proper care was not delivered because not all rights were really respected. If the mother was complaining before giving birth, a second opinion should have been sought. Both parents and midwives should remember that and look for an obstetrician review.

There is another condition to give caring a full moral sense. The one-caring must benefit the cared-for because this is good for the patient’s own sake. This is the right thing to do. Thus, morality requires evaluating intrinsically a vulnerable individual or a person. If the one caring does “care” for the vulnerable out of self-interest only, then “caring” has no moral meaning. If the one-caring is only concerned with earning money or not losing her job, then caring may not only go wrong from a technical point of view, but also could represent a moral failure. Health sciences and practices, as many philosophers have argued, are a moral enterprise. Therefore, to achieve its goal, caring needs to go with an intrinsic valuation. That is to say, the one-caring must care for the vulnerable individual’s own sake.

The conclusion cannot be other: poor care, as provided in the Baby X case, is very disrespectful indeed. I am not implying that midwives in general are not caring professionals or that a midwifery unit is not the right place for a caring decision. All I wanted to do was to discuss a case using the concept of respectful care. If we are to avoid such cases to occur again, we have not only to improve the material and the scientific conditions to provide proper care, but we need also to add a moral meaning to caring: do it respectfully.

[1] I would like to thank CAPES, a Brazilian federal agency, for supporting my research at the Oxford Uehiro Centre for Practical Ethics. I would also like to thank Steve Darwall for your conversations on the relationship between care and respect.

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6 Responses to RESPECTFUL CARE

  • Alessandro Pinzani says:

    Dear Darlei, I liked your post very much, but I have a question for you. I would like to better understand the relation between proper care and respectful care. How are they connected? Can we say that not providing proper care is eo ipso a form of disrespect? Does respectful care necessarily entails the provision of proper care? What differentiates them from each other, then?

  • Darlei says:

    Thanks, Pinzani, for reading the post and for your question. Before trying to answer it, let me say that I take the right to a decent minimum of health care as a fundamental one. Thus, I support a system of care where basic assistance is free and universally available. Now, “proper care” and “respectful care” can perhaps be used interchangeably, but I would like to reserve the later expression to mean not only that this and other rights are met, but also to add a moral dimension to care. That is to say, rights must in this view be respected not for instrumental reasons only. Thus, respectful care satisfies the three conditions presented in the post, while proper care only the first two. To sum up: respectful care is a way of intrinsically valuing a vulnerable individual; proper care not necessarily so. Is it clearer now?

  • Petry says:

    I haven’t seen any difference between respectful care and Darwall’s rational care theory. Could you explain if there is any?

  • Darlei says:

    Thanks, Petry. In fact, in order to point out all similarities and differences I would need a new post, but here is one important issue: I use the expression “respectful care” as a way to avoid paternalism in bioethics. Thus, despite the fact that care ethicists (including perhaps Darwall and myself) agree that sentiments such as sympathy and empathy are important and that the object of care is welfare or wellbeing, I believe that Darwall’s theory of rational care is in danger of paternalism. I did not develop this point in the post, but rational care does not only hold that care generates agent-neutral reasons for action, but Darwall adds an Aristotelian thesis, namely that a virtuous life is best for the agent. First, I do not see how this can possibly be applied to the case in question. Second, the Aristotelian thesis may well lead to paternalism. I do not believe that there is a single set of Aristotelian virtues to prescribe to all agents. I hope you can see the differences now.

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