14. Caring Responsibilities
© 2022 Kristien Hens, CC BY-NC-ND 4.0 https://doi.org/10.11647/OBP.0320.14
For those who make a living by talking and writing about ethics, it is often easy to forget that ethics never came in flavours of deontology or consequentialism; the principles of justice and autonomy and utility are not intrinsic properties of ethical problems. When we speak of ethical principles-or more fashionably, of a communitarian or a narrative ethic — we do so because we find these useful ways of thinking about ethics: as a self-standing conceptual system by which we can impose some sort of order upon ethical questions. But in reality, ethics does not stand apart. It is one thread in the fabric of society and it is intertwined with others. Ethical concepts are tied to a society’s customs, manners, traditions, institutions- all of the concepts that structure and informs the ways that a member of that society deals with the world. When we forget this, we are in danger of leaving the world of genuine moral experience for the world of moral fiction, a simplified, hypothetical creation suited less for practical difficulties than for intellectual convenience.
– Carl Elliott, A Philosophical Disease (Elliott, 1999, p. 146)
In a thought-provoking reflection on bioethics, A Philosophical Disease, Carl Elliott challenges the traditional toolkit of the bioethicist (Elliott, 1999). This toolkit consists of moral theories such as consequentialism, deontology, and principles. Elliott argues that they are not sufficient to deal with the complexity and even messiness of the actual world, nor should ethics be seen as an all-encompassing system that guides everything from the outside. I ended the previous chapter with the idea that it is best to stay with the trouble of accepting that ethical reflection is and always will be partial and messy—at least in the case of the seeming incompatibility of disability discourse and arguing against environmental pollution. At the same time, bioethics is practical ethics: we are often asked to develop concrete recommendations and ways to go forward with a specific new biomedical technology. The principles and moral theories we have been educated with and which we use to educate our students help clarify arguments and help us see the weaknesses and inconsistencies in our argumentations. Acknowledging the situatedness of ethical knowledge and the incompatibility of specific values does not mean that we have to give up on searching for clarity, nor that relativism—or even defeatism—is our only option. The existing bioethics toolkit can be of great assistance there. Perhaps the bioethical principles were never meant to answer ethical questions straightforwardly. Considering the context, circumstances, and particularities of specific ethical dilemmas are components of the practice of (bio)ethics, specifically in medical ethics.
The traditional bioethics approach has its limitations. A case in point is the rights of parents and their children. Children pose a significant challenge to conventional approaches to bioethics. They are gradually acquiring autonomy, one of the chief principles of bioethics. Hence, as long as they are not fully autonomous beings who can consent to their healthcare, principles such as beneficence and non-maleficence seems to trump respecting their autonomy. It remains uncertain to what extent and at which point the child’s autonomy should be respected more than the parent’s autonomy to decide on the best course of action for their child. The case of ADHD medication in children illustrates this. If a twelve-year-old wants to stop taking their medication, but the parents insist, what is the ‘good’ here? In medicine, it is often presumed that parents want the best for their children and have an ultimate say. But this need not always be the case, and parents may be wrong in some respects regarding the decisions they make for their children, or children may disagree with the decisions parents make. The child can also be wrong, but educating children always assumes some leeway for them to be misguided. After all, learning to fail is part of growing up. Dissecting parents’ and children’s potentially conflicting rights and duties using our traditional conceptual toolkit and ethical principles can be helpful. Such an approach can point out inconsistencies and gaps in knowledge. It can help clarify our thoughts about the matter and demonstrate where we need more empirical knowledge. For example, if we ask ourselves what authority parents have over their children and at which point children can have a say about their healthcare, we must acknowledge that this is highly dependent on culture and family tradition. It seems wrong and unnecessary to impose a standard ‘from above’ regarding the moment children have autonomy, and their parents’ judgment does not count. At the same time, having a general principle that the autonomy of children is important can make explicit certain unethical situations more quickly. Children are nodes in a relational network, and it is artificial to think about their autonomy rights as separate from that network. Still, autonomy rights matter too. By prying apart the respective interests of children and parents in the first move, we can bring them together better in the second move. It seems what matters is a general acknowledgement of the importance of care and relations as a foundation from which to think about the rights and duties of parents and children. In its simplest form, caring can refer to parents’ care towards their children, but it also means caring for children’s growing independence and caring for parents in complex choices. Care is not trivial. Applying principles such as autonomy and beneficence may help point out inconsistencies in conventional moral thinking, resulting in actual changes. However, principles are just that: tools that help thinking and help shed some light on different aspects that matter. Besides these tools, we need a common ground for action that is grounded in how the world works and serves as a beacon for forward-looking ethics for a liveable future. I think a care ethics approach can offer such guidance.
In Western philosophy, care ethics is a relatively modern idea. It originates from Carol Gilligan’s well-known critique of Kohlberg’s stages of morality (Gilligan, 1982). When writing Global Bioethics, Potter acknowledged the advantages of feminist approaches to morality, such as Gilligan’s.
The global bioethic must be based on a combination of rights and responsibilities in which masculinity and femininity are no longer viewed as mutually exclusive dimensions of a bipolar continuum. The concept of psychological androgyny, the endorsing of certain traditional attitudes of both males and females, and the rejection of certain others, can reorganise traditional perspectives on sex roles. The greatest barrier to the widespread acceptance of a global bioethic is the ‘macho’ morality of male autonomy and dominance: dominance over women, with unlimited reproductive function in males, and confinement of women to the reproductive role; dominance over nature; and conflict with other males. This macho morality is in part the source for the belief that a technological fix can be found for any technological disaster and for the belief that religious Holy Wars are manly. In contrast, perhaps the greatest hope for acceptance of a global bioethic is the women’s movement for reproductive freedom, followed by the ‘changed understanding of human development and a more generative view of human life’ as imagined by Gilligan. (Potter, 1988, p. 90)
Given its strong emphasis on relationality and the particularities of personal relations, care ethics is also popular among feminist bioethicists (Lindemann, 2006). At the same time, care ethics has been vetted against other approaches to bioethics, for example, principlist approaches that stress autonomy or other principles. Precisely because of this, it is sometimes claimed that in medical encounters, an ethics of care can clash with an individual’s right to autonomy. For example, a caring nurse may object to the wish of a palliative patient for euthanasia. However, it is also possible to consider respect for autonomy an integral part of care. Care ethics stresses relationality, and we can also look at the right to decide for ourselves from that relational perspective. For example, a caring approach to respect for autonomy in the case of euthanasia means thinking with the person requesting this, making them feel they are not alone in their decision. It may also imply caring for and understanding the doubts and feelings of those surrounding them. It is based on a view of life that stresses partnership and embodied communication, paraphrasing philosopher Eva Kittay (Kittay, 2019). It is, therefore, never one-directional. We are all interdependent and in need of care. Care, according to Kittay, is an ongoing process: it helps the one receiving care flourish, but they must implicitly or explicitly endorse the care offered (Skarsaune, Hanisch and Gjermestad, 2021). An ethics of care should also be seen as more than virtue ethics for doctors, nurses, and parents. Although some authors situate care firmly on the level of interpersonal relations between human beings, philosophers such as Joan Tronto have argued that an ethic of care should also have a political component. In the book Caring Democracies, Tronto defines caring as follows:
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. (Tronto, 2013, p. 19)
A bioethics that takes up a care ethic as its foundation is not a parochial endeavour that only ‘cares about’ interpersonal and private relationships. Bioethics should span both the individual and the political and consider how these are always intertwined. For starters, stressing the pervasive importance of caring for humans and other lives is in stark contrast with the attention paid to policymaking and economics. The pandemic has shown that jobs that involve caring are of utmost importance but are not traditionally linked with prestige or high wages. Care ethicists such as Joan Tronto have urged us to reconsider this and see concerns about real people’s lives as an integral part of politics.
An ethic of care that is useful for bioethicists transcends the merely human and reflects an underlying truth that human existence is entangled with the world at large. Therefore, relationality is not only between human beings but between humans and different entities, from other-than-human animals to microbes and the environment. Indeed, in Maria Puig de la Bellacasa’s ground-breaking work Matters of Care, she starts from Tronto’s idea of care as a complex, life-sustaining web and describes care as intrinsically ethical and political (de la Bellacasa, 2017). Care thus transcends the often-believed between the ethical and political. Puig de la Bellacasa advocates a concept of posthuman care that transcends the mere inter-personal and inter-human. She describes care as ‘a generalised condition that circulates through the stuff and surface of the world’ (de la Bellacasa, 2017). Thus, care is a way to think about environmental and health ethics together. It reflects an underlying truth of human existence and our entanglement with the world at large, a truth that we also find in indigenous knowledge and ecofeminism.
Environmental ethics approaches often either take the flavour of anthropocentrism or ecocentrism. Anthropocentrism refers to the belief that value is human-centred and that all other beings are means to human ends. Environmental ethics often see it as the cause of our current environmental crises (Kopnina et al., 2018). However, a more positive appreciation could be that, although anthropocentrism starts from the assumption that human beings are the primary concern, this can urge us to environmental action. If we value human life, taking environmental action is all the more important. Ecocentrism, in contrast, views human beings as an intrinsic part of nature and considers other life, and nature in itself, as having an intrinsic value. Arne Naess’s deep ecology is an example of an ecocentric approach (Naess, 1986). I also consider myself on the side of ecocentrism. I think humankind’s insistence on its superiority is misguided and even dangerous. At the same time, it is hard, and perhaps impossible, not to put one’s human life and that of one’s kin over that of other organisms. I think a care ethic approach to environmental ethics, such as we find in ecofeminism and indigenous approaches can show the way of thinking beyond the dualism of these two approaches. Vetting the rights of humans against the right of nature is not a fruitful approach. It must be possible to subscribe to an ontological ecocentrism and, at the same time, acknowledge the idea that specificity and entanglement with human and other-than-human others are morally relevant. From such a position, I think it is possible to take up an approach to environmental ethics that takes the ideas of care ethics at heart: it gives us grounds, and a method, for action. We are part of nature that has a value beyond us. However, we are also responsible for caring for nature so that we, and life in general, can recover and thrive (Cross, 2018). Acknowledging the entanglement of human well-being with environmental well-being demonstrates that environmental ethics and environmental justice are not separate things.
Such ideas are not new, nor is it very original thinking. Ecofeminists have been advocating these ideas for decades, and what is more, it has been an intricate part of indigenous thinking for centuries and even millennia.1 As Kyle Powys Whyte and Chris Cuomo conclude in their book chapter ‘Ethics of Caring in Environmental Ethics: Indigenous and Feminist Philosophies’:
Feminist and indigenous conceptions of care ethics offer a range of ideas and tools for environmental ethics, especially ones that are helpful of unearthing deep connections and moral commitment and for guiding environmental decision making. […] The gendered, feminist, historical, and decolonial dimensions of care ethics and related approaches to environmental ethics provide rich ground for rethinking and reclaiming the nature and depth of diverse relationships as the very fabric of social and ecological being. (Whyte and Cuomo, 2016)
V. F. Cordova describes how Native American philosophy views humans as primarily social, connected, and belonging to a specific place. This belonging implies that they do not ‘own’ a place but must maintain it and have intimate knowledge about it. Belonging has relevance for environmental ethics and biodiversity. Cordova writes:
The ecosystem of which he [Edward O. Wilson] speaks so eloquently is made up of interacting and interdependent communities. It is time to see that humans are part of the ecological web and that they too play a vital role-not as stewards over an inferior and mindless nature-but as a necessary part of a healthy and diverse system of life. (Cordova, 2007, p. 207)
Caring for nature is more tricky than the ethics of governing, ruling or stewarding nature. It is risking that the person, organism, or system we care for is unruly, resists, and does not conform to expectations. For bioethicists, it means encountering the challenges that other beings may pose to our firm beliefs. It means staying with the trouble of messy realities. This means accepting that we can fail and learn from this failure. Engaging in ethical argumentation is more of a learning process than finding the correct arguments that prove our point. It also means always keeping in mind what we do it for: to help ensure that those who come after us can still live a joyful and worthwhile life.
![The shell of Pinna nobilis on a white towel.",](image/X3_Pinna_Foto-IMG_2722.jpg)
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How to be inclusive to companion species?
From: Pinna Nobilis, the Great Pen Shell, is the largest mollusc living in the Mediterranean Sea. Its intimate companion species are the Neptun Sea Grass (Posidonia oceanica) and other species that live on and inside the shell. Photo: Christina Stadlbauer, 20182
1 This does not mean that indigenous concepts of care are necessarily conservative, fixed or even atavistic. Think about the concept of Buen Vivir, which is an adaptation of indigenous thinking to present-day realities(Acosta, 2012).
2 The Pinna nobilis research was undertaken by the Institute for Relocation of Biodiversity in Sant’Antioco, Sardinia (Italy) and Mar Menor, South of Spain, between 2017–2019. The 40cm long shell on the photo was found in Mar Menor. They live in the shallow waters of the Mediterranean and in antiquity they were used for their byssus thread, a fine fibre that was crafted into sea-silk and used for decorative embroidery, https://christallinarox.wordpress.com/institute-for-relocation-of-biodiversity/