An Ethnic of care
Tronto, Joan C
Generations; Fall 1998; 22, 3; ProQuest pg. 15
Ethics and Aging: Bringing the Issues Home
An Ethic of Care
By Joan C. Tronto
Despite the hospice pa-tienfs protestations, May insisted. Slowly, she helped him up to sit with her in the kitchen while she heated up the food that Meals on Wheels had sent for him.
The union meeting at the nursing home had grown more and more angry. In the end, the nurses' aides agreed w strike if more staff were not hired. In their letter to management, they wrote, aWe simply do not have enough time to take care of the patients^
The agency head despaired. She had received an angry phone call from a woman whose mother received home-help assistance from her agency. The daughter reported that a five-dollar bill that she had left on her mother's dresser had disappeared after the aide visited yesterday. The administration could fire the aide, but this was the fourth aide she had sent to the household in the past year.
Such vignettes are familiar in caregiving and raise a number of significant questions. But are the questions they raise ethical questions?
One of the central tasks
is to change the overall public value associated with care.
Often in our culture, ethical and moral seem to refer to conformity to set principles and precepts: stealing is wrong, do not lie. "Ethics" and "morality" seem to evoke big questions, impossible dilemmas, or conformity to pre-determined codes of behavior. By this account, there is no obvious moral issue in insisting that a dying patient continue to be engaged in life, or in
_____—_---„„  staffing levels in a nursing
home. This essay describes a way of thinking about caring that expands our notions of the "ethical" to include many of the everyday judgments involved in activities of caring for ourselves and others. The paper draws upon a body of recent work in the feminist ethics of care (Benner and Wrubel, 1989; Fisher and Tronto, 1990; Ruddick, 1990; Manning, 1992; Held, 1993; Tronto, 1993; Bubeck, 1995; Held, 1995; Jaggar, 1995; Sevenhuijsen, 1998) to present a more complicated account of ethics, one that tries to restore to the word ethics its original meaning—knowledge about how to live a good life. This perspective requires not only a broader interpretation of the nature of
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Generations
ethics, but a more complete account of the nature of care. In making daily and thoughtful judgments about caring, people every' day engage in a high moral calling. Our moral sensibilities will be greatly enhanced if we learn to think more thoughtfully about the morality of everyday life embodied in an ethics of care.
A Broad Understanding of Care
VVhen Berenice Fisher and I began to explore the nature of care (Fisher andTronto, 1990), we were surprised that we could find no good and systematic definition of the term. As many commentators have observed, care has a dual set of meanings. It refers both to a mental disposition of concern and to actual practices that we engage in as a result of these concerns; for example, a doctor's care involves both an attentive-ness and concern and the concrete practices of prescribing medical treatment (Hugman, 1991). Nevertheless, much of the current discussion of care either overemphasizes the emotional and intellectual qualities and ignores its reference to actual work, or overemphasizes care as work at the expense of understanding the deeper intellectual and emotional qualities.
The activities that constitute care are crucial for human life. We defined care in this way: Care is "a species activity that includes everything that we do to maintain, continue, and repair our Svorld' so that we can live in it as well as possible. That wrorld includes our bodies, our selves, and our environment, all of which we seek to interweave in a complex, life-sustaining web" (Fisher and Tronto, 1990, p. 40).
Several aspects of this definition of care are noteworthy: First, we describe care as a "species activity," a philosophical term we use because it suggests that how people care for one another is one of the features that make people human. Second, we describe care as an action, as a practice, not as a set of principles or rules. Third, our notion of care contains a standard, but a flexible one: We care so that we can live in the world as well as possible. The understanding of what will be good care depends upon the way of life, the set of values and conditions, of the people engaged in the caring practice.
Furthermore, caring is a process that can occur in a variety of institutions and settings.
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Care is found in the household, in services and goods sold in the market, in the workings of bureaucratic organizations in contemporary life. Care is not restricted to the traditional realm of mother's work, to welfare agencies, or to hired domestic servants but is found in all of these realms. Indeed, concerns about care permeate our daily lives, the institutions in the modern marketplace, the corridors of government. Because we tend to follow the traditional division of the world into public and private spheres and to think of caring as an aspect of private life, care is usually associated with activities of the house-hold. As a result, caring is gready undervalued in our culture—in the assumption that caring is somehow "women's work," in perceptions of caring occupations, in the wages and salaries paid to workers engaged in provision of care, in the assumption that care is menial. One of the central tasks for people interested in care is to change the overall public value associated with care. When our public values and priorities reflect the role that care actually plays in our lives, our world will be organized quite differently.
Four Phases of Care
Until the world changes, though, an analysis of care can provide us with a useful guide for thinking about how we do our particular caring work and its ethical dimensions—the way in wiiich care is related to what we know about how to live a good life. Such a process can also provide us with a framework for political change. Thinking about the process of care, Fisher and Tronto (1990) identified four phases of care as follow:
Caring about. "Caring about" involves becoming aware of and paying attention to the need for caring. Genuinely to care about someone, some people, or something requires listening to articulated needs, recognizing unspoken needs, distinguishing among and deciding which needs to care about. It requires attentiveness, that is, of being able to perceive needs in self and others and to perceive them with as little distortion as possible, which could be said to be a moral or ethical quality.
Caring fir. "Caring for" is the phase in caring when someone assumes responsibility to meet a need that has been identified. Simply seeing
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Ethics and Aging: Bringing the Issues Home
a need for care is not enough to make care happen; someone has to assume the responsibility for organizing, marshaling resources or personnel, and paying for the care work that will meet the identified needs. The moral dimension of caring for is to assume, and to take seriously, responsibility.
Caregiving. This phase is the actual material meeting of the caring need. Caregiving requires that individuals and organizations perform the necessary caring tasks. It involves knowledge about how to care. Although we often do not think of it this way, competence is the moral dimension of caregiving. Incompetent care is not only a technical problem, but a moral one.
Care receiving. This phase involves the response of the thing, person, or group that received the caregiving. Whether the needs have been met or not, whether the caregiving was successful or not, there will be some response to the care that has been given. Care receiving requires the complex moral element of responsiveness. Responsiveness is complex because it shares the moral burden among the person, thing, or group that has received the care, but it also involves the moral attention of the ones who are doing the caring work and those who are responsible for care. In a way, since any single act of care may alter the situation and produce new needs for care, the caring process in this way comes full circle, with responsiveness requiring more attentiveness.
Identifying these four phases of care provides us with a more complex picture of what "good caring" will be. It allows us to recognize that while there may be an ideal form of caring, an integrated holistic process in which those who cared about a problem take responsibility, provide care, and receive thanks when all goes well, to realize this ideal process of caring is highly unlikely. In reality, the process of care rarely occurs in a perfect way.
Several aspects of care make it much more complicated than this account of phases might suggest. In the first place, care is fraught with conflict. Indeed, conflict seems inherent in care. There are more needs for care than can ever be met. Determining which needs are important inevitably involves slighting other needs. At the most personal level, caregivers have needs at the
same time that they give care to others, and they need somehow to balance their needs and those of others. At the institutional level, the needs of different clients, groups, and workers may come into conflict with each other. At the political level, a prominent form of political struggle occurs over the recognition of needs, and for individuals and groups to be able to describe their needs (what the political theorist Nancy Fraser [1989] has called a "needs interpretation process").
In the second place, care involves power relations. Care can occur among equals, and some care (called "personal service" by Kari Waerness [1990] and including such cases as doing the cleaning or laundry for others in one's household) is provided by subordinates for people who could otherwise provide this kind of care for themselves. But much care, and much care for the elderly, is what Waerness calls "necessary care": the caregiver has some kind of ability, knowledge, or resource that the care receiver does not have. As a result, there is often an imbalance in power among caregivers and care receivers. Sometimes the relationship between caregivers and receivers becomes a power struggle. Sometimes the care receiver becomes filled with rage. That any party might abuse a caring relationship and take advantage of the others is also possible.
When people recognize that care is a complex process with many components, it becomes possible to avoid either despairing about care or romanticizing it. Care is more likely to be filled with inner contradictions, conflict, and frustration than it is to resemble the idealized interactions of mother and child or teacher and student or nurse and patient.
Making Caring Judgments
The ethic of care, then, both elevates care to a central value in human life and recognizes that care requires a complicated process of judgment. People need to make moral judgments, political judgments, technical judgments, and psychological judgments in their everyday caring activities. Caring, then, is neither simple nor banal; it requires know-how and judgment, and to make such judgments as well as possible becomes the moral task of engaging in care. In
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general, care judgments require that those involved understand the complexity of the process in which thev are enmeshed. Caring involves both rational explications of needs and sympathetic appreciation of emotions. It requires not an abstraction from the concrete case to a universal principle, but an explication of the "full story" Yet, at the same time, those engaged in care practices need to be able to place some distance from their own version of what is happening and other perspectives.
The experience of people working in caring agencies, caregivers, and people who reflect on the caring practices of their everyday lives suggests that using this framework for analysis helps people to pinpoint problems in caring processes and relationships. Using the (probably un-
achievable) goal of a unified, satisfying process of care as a guide, thinking about care in this more complex way that is linked to morality and ethics allows people to act to improve the situations in which they find themselves. While perfection is impossible, improvement is not; through good caring, people are better able to live in the world.
There are at least three kinds of moral problems related to the practice of care that require reflection. In the first place, problems may arise in thinking about the particular elements of care. In the second place, problems arise from the conflict inherent in care and in the difficulties of integrating the phases of care. In the third place, the context in which caring work occurs also presents moral problems. (The box below
Questions That Can Guide Caring Judgments
Questions that arise from the elements of care:
1. Attentiveness. What care is necessary? Are there basic human needs? What types of care now exist; how adequate are they? Who gets to articulate the nature of needs and to say what and how which problems should be cared about?
2. Responsibility. Who should be responsible for meeting the needs for care that do exist? How can and should such responsibility be fixed? Why?
3. Competence. Who actually are the caregivers? How well do they do their work? What conflicts exist between them and care receivers? What resources do caregivers need in order to care competentiy? WTio pays attention to changes in care receivers' needs?
4. Responsiveness. How do care receivers respond to the care that they are given? How well does the care process, as it exists, meet their needs? If their needs conflict with one another, who resolves these conflicts?
Questions that arise from conflict and integration of care:
i. What conflicts exist to disrupt integrated
and complete care?
2. How far apart are caregivers and care receivers?
3. How distant from those who give care are those who hold "responsibility"?
4. What connection exists to make those who claim to "care about" a particular problem assume responsibility for it, and pay attention genuinely to its outcome as a caring process?
5. What conflicts emerge between the expertise of those who care about, care for, and give care, and those who primarily receive care?
Questions that arise from the context of care:
1. How are needs understood to define and to shape the nature of the caring process?
2. What forms of power and privilege reside in this care process? How do they shape the nature and adequacy of care? Do they threaten change in current forms of care?
3. What construction of "otherness" (for example, positing "the vulnerable" as "others" who are unlike ourselves) contributes to perceptions of caring?
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Ethics and Aging: Bringing the Issues Home
lists some of the questions that are relevant to explore in thinking about caring.)
A final implication follows from the complexity of the care process and underscores the importance of the "full story" being heard in making judgments about care. Caring should take place in an environment in which all of those engaged in caring—caregivers and care receivers as well as other responsible parties — can contribute to the ongoing discussion of caring needs and how to meet them. No single actors in a care process can assert their own authoritative knowledge in the process. Within the activity of caring itself, actors must continue to be attentive, responsible, competent, and responsive to the others in the caring process.
The Care Ethic, Vulnerability, and Caring for the Elderly
Caring is complex, but it is also ubiquitous. Yet we live in a culture that finds it very difficult to acknowledge this fact, for many possible reasons. Perhaps such unwillingness partly stems from a "model of man" that presumes that people are autonomous actors, and so people are unwilling to recognize their own caring needs as legitimate. It may also stem from the unlimited nature of needs, so that when people begin to acknowledge the needs of others they are quickly frustrated by their relative inability to meet all of these needs. Partly, this unwillingness probably stems from a division of the world into public and private realms, in which "caring" is supposed to be done in private, away from public view. And, in part, the unwillingness to recognize the role of care in our lives probably stems from our incapacity to comprehend death. No matter how successfully we care for ourselves or others, human life ends in death.
While the elderly do have particular needs, there is a danger in trying to think about the care needs of the elderly as separate from the broader context—even-one has caring needs. Elderly people care for themselves, and they also care for their families, their friends and neighbors, their communities, and the commonweal. The elderly also receive care from many others. The diversity of practices required to care for el-
derly people's needs is as great as the diversity of caring for people of other ages. Although some older people are not so, many older people are more vulnerable than they were when thev were younger. The processes of aging make some elderly people more vulnerable to some physical and mental incapacities. Elderly people might find themselves in the situation of needing the assistance of others in meeting their needs, and, as a result, may have to change their sense of power in relations of care as diey age. Among the elderly, people have different access to resources with which to care for themselves. This fact raises many moral questions about equity in providing for the care of the elderlv.
Perhaps what is the most interesting point to notice about the caring needs of the elderly, though, is not so much the nature of the actual needs, but rather the fact that the elderlv seem to be "marked" with an assumption that diey need more assistance. As a society, our unwillingness to acknowledge our own vulnerability demands the easy solution of identifying particular groups as especially vulnerable, so that we can continue the myth of our own invulnerable autonomy. In a society in which vulnerability is viewed as weakness, those who are perceived to need more care, regardless of the actual situation, are in a more vulnerable position. In fact, many older people do have greater needs for care: healthcare, physical space, transportation, and housing. Yet as long as these discussions take place in a context in which the elderlv are marked as the vulnerable ones, in need of "special" care, we miss our opportunity to see caring in old age as part of a full life process. Embracing care as a part of human life, recognizing its role in creating interconnections and relationships of receiving and giving over a lifetime, may provide us with a way to rethink some of the ways in which we now seem unable to cope widi human vulnerability. This is not a problem that concerns only the elderly, it is one that affects everyone.
Conclusion
The ethic of care, as feminist theorists have articulated it, provides opportunities for people to analvze their own activities of care as well as to understand the broader place of caring in
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human life. To return to die examples at the beginning of this essay, conflicts between enraged patients and their caregivers, between management and care workers in institutions, are part of this process. Coming to some resolution of these conflicts is part of the essence of caring activities themselves. It requires thoughtful judgments that involve all who are concerned. Through thoughtful engagement in caring, we can begin to recognize the profound moral dimensions of our everyday lives,
Joan C. Tronto, Ph.D., is professor of political science and former coordinator, Women's Studies Prop-am, Hunter College, City University of New York.
References
Benner, P., and Wrubcl, J. 1989. The Primacy of Caring: Sttvss and Coping in Health and Illness. Menlo Park, Calif.: Addison-Weslcv.
Bubeck, D. 1995. Care, Justice and Gender. Oxford, England: Oxford University Press.
Fisher, B., and Tronto, J. 1990. "Towards a Feminist Theory of Care." In E. Abel and M. Nelson, eds., Circles of Care. Albany, N. Y.: State University of New York Press.
Fraser, N. 1989. Unruly Practices: Pmvei; Discourse, and
Gender in Contemporary Social TJjemy. Minneapolis: University of Minnesota Press.
Held, Y 199;. Feminist Morality: Transforming Culture, Society and Politics. Chicago: University of Chicago Press.
Held, V 1995. Justice and Care: Essential Readings in Feminist Ethics. Boulder, Colo.: Westview Press.
Hugman, R. 1991. Power in Caring Pwfessions. London: MacMillan.
Jaggar, A. 1995- "Caring as a Feminist Practice of Moral Reason." In V Held, cd. Justice and Care: Essential Readings in Feminist Ethics. Boulder, Colo.: West-view Press.
Manning, R. 1992. Speaking From the Heart: A Feminist Perspective on Ethics. Lanham, Md.: Rowman and Lirdefield.
Ruddick, S. 1990. Aiatemal Thinking: Towards a Politics of Peace. Boston: Beacon Press
Sevenhuijsen, S. 1998. Citizenship and the Ethics of Care. New York: Roudedge.
Tronto, J, 1993. Moral Boundaries: A Political Argument for an Ethic of Care. New York: Roudedge.
Waerness, K. 1990. "Informal and Formal Care in Old Age: WTiat Is Wrong With the New Ideology in Scandinavia Today.-" in C. Ungerson, ed., Gender and Caring: Work and Welfare in Britain and Scatidinavia. London: Harvester, Wheatsheaf.
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