“For an attention-oriented medicine and care”

Efficiency orientation is compromising the basics of care

by Professor Dr med. Giovanni Maio

sv. A small group of active retirees from the nursing care professions have made it their concern to address current issues in the health care system. With its first major conference in St. Gallen in June 2019, it wanted to make employees from the health and social sectors and all other interested parties aware of the problems of economisation and discuss solutions with them. The increasing demand for efficiency and profitability in hospitals, clinics and homes is leading to work pressure, a shortage of staff and the associated lack of time as well as increasing bureaucratisation. As a result, conversations, building relationships and attention are becoming less and less important.
    The event clearly showed that many people are practicing the medical and nursing professions with devotion, but that the increasing, all-pervading economisation is shaking the foundations of these professions. This was also pointed out by Professor Giovanni Maio, consultant in medicine and holder of the chair of medical ethics in Freiburg im Breisgau. In the following we reprint an article from the Swiss Association of Nursing Professionals’ magazine “Krankenpflege” presenting the reflections he presented at the conference as well as his great appreciation of the nursing professions.

Elements of an Ethics of Care

The goal of care is not healing in the first place, but integrity. This makes it unique. However, under the pressure of efficiency and rationalisation, care is running the risk of losing the basis of its identity: care for the infirm, which can only be achieved through relationships.
Care is one of the original manifestations of help and support. It is an indispensable part of a society because it is the answer to a basic human need. This alone indicates that nursing is not simply an auxiliary discipline of medicine but an independent discipline with its own task, objectives, methodology and value. Therefore, nursing must defend its identity with guts and self-confidence, against all – also and above all bureaucratic – attempts at its transformation. Care has a goal like no other profession; its goal is not healing but integrity. Nursing is a profession that creates integrity; it seeks to direct the infirm towards a new wholeness, a wholeness of its own kind, not to be confused with healing. Because, particularly where healing is not possible, care strives to enable a feeling of healing within a sick or frail body, a feeling of wholeness, a feeling to be more than just disabled. Care works to restore a sense of integrity to the other person, and this is only possible by having the goal in mind to establish integrity in a comprehensive sense, namely as an expression of a balance of physical and mental well-being. Ultimately, care aims at nothing more than the preconditions for the physical comfort of the whole person (Maio 2017).
Care wants to make the body, which in illness is often perceived as strange, a familiar body again; it is a profession of familiarising oneself with a body that escapes the experiences made with it so far. Care has to do with helping a person to become friends with his or her disability in order to perceive his or her own body as part of himself or herself, even in its damaged and often disfigured and sometimes dysfunctional form, and as part of a task for which it is worth getting involved.

“Therefore, care is not only about performance, application and doing, but also about investing in a trusting relationship. Good care is to be understood in an essential sense as the result of a successful interaction, which is indispensably dependent on personal attention. Thus, the care of people in need cannot be about offering an impersonal service. Care depends on a dialogue that can be conducted with words, gestures and tactful touch.”

 

Indispensable Care

No other profession has this goal which is what makes it a discipline with its own value and, above all, with its own indispensability like hardly any other profession. Indispensable, because without this care every disabled person would fall into despair and possibly give himself or herself up. Care is therefore a fundamentally positive profession. It accepts disability in order to promote the preserved healthy parts and to show people that they can also do something with their sick body – and thus, despite the need for care, they are not at the mercy of care, but can participate in the smallest facets of even the most disabled life.
To achieve this goal, care inevitably relies on interacting with the patients or residents in all their activities. Therefore, care is not only about performance, application and doing, but also about investing in a trusting relationship. Good care is to be understood in an essential sense as the result of a successful interaction, which is indispensably dependent on personal attention. Thus, the care of people in need cannot be about offering an impersonal service. Care depends on a dialogue that can be conducted with words, gestures and tactful touch. We can only understand the significance of this dialogue in terms of personal attention if we understand nursing care as a practice of caring for others.

“Bureaucratic logic tries to simplify reality as much as possible. Consequently, nursing professionals are urged to reduce not only their work but also the situation of the patient to a suitable keyword. Living realities are transformed into linear models of causality and anything challenging this linearisation gets homogenised. However, the situation of the patient cannot be depicted in linear models. It cannot be pinned down by keywords but requires a deeper understanding, the appreciation of wholeness.”

Eight Elements of an ethics of care in nursing

Regarding ethics, no other term is as closely linked with nursing as “care”. Like the High Dutch term “Sorge” the English term “care” – active commitment to enhance the well-being of people in need (Conradi 2001) – goes hand in hand with the term “nursing”. Despite all more recent phraseology (customer service, productivity, efficiency) the identity of nursing is still intimately linked with the term “care”. Certain commitments and convictions indicate the orientation towards the principle of care, because if nursing is understood as a practice of care the question about the moral framework which guides this rationale of care inevitably poses itself.

1. Acknowledging dependence

Acknowledging the basic dependence of each human being is the starting point of the ethics of care. While keeping focussed on the sovereignty of each individual ethics of care does not neglect the fact that this sovereignty will not develop on its own but from preconditions which need to be provided by others. The simple reason for this is that every human being always remains dependent on support, regardless of whether he or she realises this fact or whether it remains subconscious. The peculiar properties of the ethics of care become evident at this very point where dependence is set free of its negative connotation: being-in-need of help is no longer regarded as a sign of infirmity, but rather normality.  

2. Significance of relatedness

Ethics of care define being human as being related to other human beings. This way relatedness becomes a window of awareness for ethical problems. Therefore, it is understandable why ethics of care regards relatedness as crucial for the solution of ethical problems. Consequently, virtues stabilising relations such as forbearance, forgiveness, devotion und trust are held in high esteem.  Ethics of care implicitly re-evaluates affective bonds and the importance of interaction as essential for the solution of ethical conflicts.  
Especially for nursing professionals a focus on relatedness is always a dangerous path because they have-to keep enough emotional distance to avoid self-exploitation. Even though the limits of relatedness as a means-to solve problems become visible at this point, still there is good reason to stress the moral dimension of relations and to value relation-stabilising virtues as indispensable hallmarks of the ethics of care.  

3. Orientation towards situations

Rather than defining abstract rules and proceeding to practice from there, ethics of care takes practice as its starting point. Each situation in its distinct uniqueness poses a task to react in the way which seems to be most appropriate at this very moment. Since merely following guidelines will never match a concrete situation adequately, ethics of care prefers generating answers ad hoc. Singularity and particularity replace strict general rules. Basically, the core challenge of care is to appreciate and to protect the uniqueness of the other (Ricoeur 2005).
Situational creativity is the ability needed for this task. The awareness of being governed by the situation in one’s own acts and the sensibility to maintain an open attitude and the preparedness to always remain approachable in the double sense of the word are crucial.  In conclusion this aspect of being governed by the situation may be divided into three elements: (1) stressing the directness and appreciation of direct intuition (2) acknowledging the distinct uniqueness of the situation and (3) necessity of a creative rather than merely guideline-informed orientation.

Professor Dr med. Giovanni Maio studied philosophy and medicine. After many years of work in internal medicine and clinical practice, followed by a period as an assistant at medical theoretical institutes, he habilitated in the field of ethics in medicine (July 2000). In 2002 he was appointed to the Central Ethics Committee for Stem Cell Research by the German Federal Government. In 2004 he has been offered a chair as C4-Professor for Medical Ethics and History of Medicine at the University of Bochum. In 2004 he has been offered a chair as C4-Professor for History and Ethics of Medicine at the RWTH Aachen University, in 2005 he has been offered  the Chair of Biomedical Ethics at the University of Zurich, and in 2005 he has been offered the Chair of Bioethics/Medical Ethics at the Albert-Ludwigs-University Freiburg (accepted). He is a member of the board of directors of the Interdisciplinary Ethics Centre Freiburg, director of the Institute for Ethics und History of Medicine, member of the Committee for Ethical and Medical Judicial Basic Policy Issues of the German Medical Association.
In his publications since 1998, Giovanni Maio has been committed to human medicine. In 2018, his book „Werte für die Medizin. Warum die Heilberufe ihre eigene Identität verteidigen müssen“ (Ethic values for medicine. Why the healing professions must defend their own identity) (Munich: Kösel) was published. The second edition of his medical ethics textbook „Mittelpunkt Mensch. Lehrbuch der Ethik in der Medizin“ (2017) (Focus on the human being. Textbook of Ethics in Medicine) contains an introduction to the ethics of care and twelve completely new chapters on topics such as the concept of health, the concept of disease, discourse ethics, care ethics, hermeneutic ethics, human dignity, the ethics of nursing care, neuroethics, etc. (Stuttgart: Schattauer).

 

4. Mastering ambiguity

Since the concrete situation is the starting point for an ethics of care, the result of the ethical conclusion is measured quite differently as compared with deductive ethics. The latter entertains the notions of exactness and unambiguousness: Is it allowed or forbidden? Indicated or not?  Right or wrong? For ethics of care such questions are not the most important ones to ask. Instead, a certain tolerance of ambiguity is inevitably connected with ethics of care, a preparedness to maintain states of undecidedness. For the rationality of care ambivalence is by no means a state which needs to be dissolved at any costs.  
Mastering ambiguity may therefore be regarded as a core competence of care. There is not the one and only solution but a whole spectrum of solutions, there is not the right thing to do but rather the most appropriate and there is no objectively correct solution satisfying a universal requirement. The situation of the patient and the subsequent challenges are ambiguous and multi-facetted. Although it is often claimed otherwise, they call for the appreciation of nuances and shadings rather than binary decision trees. At the end of the day it is about enduring ambiguousness because this is the only way to grasp the situation of the patient and his or her emotional state. Therefore, for the ethics of care the ability to handle complexity plays an important role.

“It must be the task of care to strengthen people, to accompany them, to accept them, to further them by assisting their very own competences and resources. It is not about the strategic solution of a problem, but about interpersonal support on the way to mobilising the patients’ own potential, no matter how small, rudimentary or limited it may be. To return this their potential to the patients, that is the real task of care.”

 

5. Responsivity

The peculiarity of an ethics of care is the fact that its defining mode of action is not the initiative but rather the response, the answer it gives when being engaged by the human-being in need of help. Care for the other is primarily responsive. It is the other, who reaches out to call for care, so-to-speak. Therefore, the ethics of care invoke the art of listening. It is always associated with the habit and gesture of attention. The corresponding basic attitude is responsivity, receptive appreciation, deep mindfulness.
At the same time ethics of care are associated with the impulse for change, the impulse to realise care, which becomes apparent with the recognition of the mischief the other is in. Especially because of its inherent responsiveness ethics of care are not compatible with merely following schematic to-do-lists. Ethics of care are not realised by checking such lists but by the impetus to find a direct and immediate answer to the situation of the patient, his emotions and needs, here and now. In this sense, Emmanuel Lévinas referred to care as “being-engaged” by the other.

6. The importance of emotional wisdom

The crucial role of relatedness, the demand to adequately recognise each situation and the preference for creative solution strategies call for implicit kinds of knowledge such as experience, situational and relational knowledge. There is no way to learn these by heart, they have to be practiced.
Care can only be realised by engaging all senses, one can only find out what needs to be done when standing at the bedside and using all senses to perceive the patient in his or her current situation rather than just knowing the diagnosis and studying the patient’s notes. It is mandatory for the realisation of care to experience the whole atmospheric tune: only then the patient can be assured to be appreciated as a subject. For this reason, a central mode of care is a keen sense of association, of what is appropriate and important at this very point in time. One can only train this sense by daring to overcome the mode of objectification when interacting with the patient but enhance it with additional ways of perception. Ethics of care acknowledge this keen sense and its implicit ways of knowledge as values-in-itself. Insofar ethics of care is especially progressive because it appreciates emotional wisdom as a kind of knowledge, takes it seriously and therefore is an implicit plea for general re-evaluation of emotional knowledge.
Therefore, nursing needs to meet the challenge not to put this emotional wisdom in opposition to cognitive knowledge but to recognise the necessity to find a healthy balance between the two kinds of knowing things: emotional wisdom is re-evaluated on a higher level as a creative factor but at the same time cognitive knowledge remains present as a constant tool of appraisal. Ethics of care can only become fruitful if it paves the way for creative solutions by means of emotional wisdom, without neglecting the duty to always explain these solution strategies in public discourse with transparent and convincing arguments.

7. The basic attidude of cautiously proceeding

Since ethics of care focusses on the awareness of complexity the reaction to ethically relevant problem will be evaluated by criteria different from those guided by the principles of functionality and efficiency. What counts is tentative manoeuvring and caution rather than swift and self-confident action.
From this background, nursing needs to be regarded as the discipline of cautions manoeuvres and fine balances. The way to find the right the balance is derived from the direct encounter with the patient. Expertise in nursing is the art of fine-tuning, therefore indispensable basic dispositions for this art are subtlety, discretion and tactfulness. While it is often assumed that in our super-modern world all working procedures are subject to formalisation, but in nursing interaction with the patient is more than formal to-do-lists. How things are performed is always as important as sticking to the work list. Nursing always means working in immediateness rather than abstract working schemes.

8. Appreciating wholeness

Bureaucratic logic tries to simplify reality as much as possible. Consequently, nursing professionals are urged to reduce not only their work but also the situation of the patient to a suitable keyword. Living realities are transformed into linear models of causality and anything challenging this linearisation gets homoge- nised. However, the situation of the patient cannot be depicted in linear models. It cannot be pinned down by keywords but requires a deeper understanding, the appreciation of wholeness. Always the whole connection of various problematic aspects has-to be pictured at once. This requires integrative thinking, the ability to integrate the multiplicity of aspects. Picturing wholeness from multiple perspectives is desirable as the only way the appreciate how the patient really feels. Ethics of care requires this way of appreciation and understanding, therefore the rationality of care is at the end of the day thinking in complexity, since it inevitably aims for an appreciation of wholeness.

“Therefore the realisation of an ethic of care will only succeed if the fact is recognised throughout the system that care needs time and attention […]. Making possible this kind of care not only serves the person in need of care, but also the system of caretaking and the caretakers themselves, because they can only identify with their actions on the basis of a lived ethics of care and because, on this basis, their actions will be richly rewarded inasmuch as they make interpersonal relationships possible.”

 

Conclusion: Care as a practice of support and affectionate attention

If we look at the points elaborated here as a whole, then we can conclude: It must be the task of care to strengthen people, to accompany them, to accept them, to further them by assisting their very own competences and resources. It is not about the strategic solution of a problem, but about interpersonal support on the way to mobilising the patients’ own potential, no matter how small, rudimentary or limited it may be. To return this their potential to the patients, that is the real task of care. And this can only be achieved through a quiet rationality, a rationality that cannot be documented, that cannot be laid down in algorithms. There is no codified plan of action to strengthen human resources, but this can only be achieved through relationship work, through caring.
It is a rationality of caring that comes to the fore here, and this kind of rationality cannot be completely formalised because it is not primarily instrumentally rational; it is, instead, a hermeneutic rationality. It is mainly linked to understanding and not primarily to strategic functional thinking.
Therefore the realisation of an ethic of care will only succeed if the fact is recognised throughout the system that care needs time and attention and that the core content of care cannot be measured, but can, when all is said and done, only be experienced – experienced in the healing atmosphere that arises when care is not reduced to caring for the body, but if the caretakers are given the opportunity to practice body care on the basis of realising a relationship that has to be worked at daily. Making possible this kind of care not only serves the person in need of care, but also the system of caretaking and the caretakers themselves, because they can only identify with their actions on the basis of a lived ethics of care and because, on this basis, their actions will be richly rewarded inasmuch as they make interpersonal relationships possible.    •

Literature
Conradi, Elisabeth. Take Care. Grundlagen einer Ethik der Achtsamkeit. (Take Care. Basics of an ethic of mindfulness.) Frankfurt 2001
Maio, Giovanni. Mittelpunkt Mensch. Lehrbuch der Ethik in der Medizin. Mit einer Einführung in die Ethik der Pflege. (Focus on the human being. Textbook of ethics in medicine. With an introduction to the ethics of care.) Stuttgart 2017
Ricoeur, Paul. Das Selbst als ein Anderer. (The self as another.) Paderborn 2005

Source: Erstveröffentlichung in Krankenpflege 04/2019. (First publication in sick-nursing), reprinted with kind permission of the author.

(Translation Current Concerns)

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