Caring About Health

Stan van Hooft

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351162029
• Edition: 1
• Topic: Philosophy
• Subtopic: Philosophy History & Theory

Presenting a philosophical exploration of the ideas central to health care practice this book explores such concepts as caring, health, disease, suffering and pain from a phenomenological perspective. With deep philosophical insight this book draws out, not only the ethical demands that arise when one encounters these phenomena, but also the forms of ethical education that would help health care workers respond to those demands. This is a book which explores the grounds for ethical living rather than enunciating ethical principles. Van Hooft argues that ethical responses arise from sensitive and insightful awareness of what is salient in clinical and other health care settings. This book draws upon thinkers from the classical canon, the Anglo-American tradition and from continental philosophical ideas.

Part 1
Health Care, Virtue and Education

Chapter 1
Caring and Professional Commitment

A great deal of writing about the professional life of nurses stresses the concept of caring. It has become almost traditional to distinguish the role of the medical practitioner from that of the nurse by saying that the former seeks to cure the patient while the latter cares for him or her. Even though warnings have been sounded that this distinction between caring and curing may be an ideological cover for the historically contingent nurse–doctor distinction,¹ and that it is improperly based on gender distinctions,² it seems clear that there is a role for caring in therapy even if the question as to who exercises that role might receive different answers at different times. Equally clearly it seems that it is the nurse who most centrally occupies that role at this historical juncture. In any case it is imperative that there be some degree of clarity as to what is meant by caring, both in general terms and in terms suitable to the context of a nurse's professional life. It will be my contention in this chapter that not enough discrimination has been displayed by many writers on this topic and that the ideal of caring is consequently in danger of becoming an unattainable goal. I shall then propose an alternative way of thinking of the central objectives of a nurse's professional activities.

The notion of caring

I will begin with some quotations in order to indicate how caring is spoken about in the nursing literature. Firstly, here is Simone Roach:

Nursing is a personal service, a science and an art practised within a relationship, in itself, therapeutic. This ... presupposes a personal commitment which expresses itself in what may be the most intrinsically human of human acts – the act of caring.³

Jean Watson offers the following:

Caring is viewed as the moral ideal of nursing where there is the utmost concern for human dignity and preservation of humanity. Human care can begin when the nurse enters into the life space or phenomenal field of another person, is able to detect the other person's condition of being (spirit, soul), feels this condition within him or herself, and responds to the condition in such a way that the recipient has a release of subjective feelings and thoughts he or she had been longing to release. As such, there is an intersubjective flow between the nurse and patient.⁴

It seems clear that what is being recommended here is a vocation of service to one's fellow human beings and the establishing of a relationship between nurse and patient of some considerable intimacy: one that is marked for the nurse by deep empathy and rapport, and for the patient by a catharsis of pent-up feeling.

Now it might be suggested that these quotations are not typical and should therefore not be taken as representative. The literature contains a variety of views about what caring is, ranging from the sorts of intimacy just alluded to, to a more level-headed application of caring procedures. However, it is striking that whatever the specific proposal might be for what constitutes caring practice, the notion of caring as such is frequently adumbrated with reference to a quite limited set of authors, a set which almost always features Milton Mayeroff and Martin Buber. So we see Barbara Carper,⁵ Doris Riemen⁶ and Barbara Blattner⁷ alluding to the first, while Madeleine Leininger⁸ refers to the second and Watson⁹ cites both. Even when these authors are not explicitly cited, they frequently appear in the bibliographies of the literature of caring. But what sort of notion of caring emerges from them?

For Mayeroff, caring is defined as helping the other to grow in a full, personal sense, although he makes it clear right at the outset of his text that 'the other' here might include ideas and ideals as well as persons. However, as this notion is applied to nursing (for example, by Blattner) the proper object for the caring relationship becomes the person. For Mayeroff the special features of caring for a person require that: 'I must be able to understand him and his world as if I were inside it.'¹⁰ In developing this idea, Blattner says:

Caring is the interactive process by which the nurse and client help each other to grow, actualize and transform towards higher levels of well-being. Caring is achieved by a conscious and intuitive opening of self to another, by purposefully trusting and sharing energy, experience, ideas, techniques and knowledge.¹¹

It is striking that along with techniques and knowledge, what is being called for here includes 'trusting', 'sharing' and 'opening' of self to another. Mayeroff's own eloquent text calls as well for patience, honesty, humility, hope and courage. While there is no doubt that these are personal motivational qualities that are inherently valuable and therefore valuable in a nursing context, it may be questioned whether they are sufficiently specific to nursing to constitute features of that particular form of care that nurses should evince. After all, shouldn't any sensitive person display such qualities when they enjoy such an intimate relationship as caring for another? There remains a question of how this applies specifically to nursing.

Indeed, there are striking points made by Mayeroff which call into question the suitability of his model for the profession of nursing. For example, he suggests that any person who cannot grow cannot be cared for in his sense.¹² This would rule out a brain-damaged person who does not have the physical requirements for intellectual or emotional development. Yet such a person needs to be looked after. Can we not call the activities engaged in, in the course of looking after such a person, 'caring'? Even if it were answered that a brain-damaged person has some potential for growth, the point could still be made that making the caring relationship dependent upon an ability of the recipient seems to be inappropriate.

Mayeroff¹³ goes on to suggest that the caring relationship breaks down if there is a constant replacement of the person being cared for by another; that there is a degree of permanence and irreplaceability involved in the caring relationship. But surely a nurse owes a duty of care to both short-term and long-term patients. Is the quality of care applicable to the former to be poorer because short-term patients are constantly being replaced by new cases? It becomes clear further into Mayeroff's text that the interpersonal relationship of which he speaks is one of greater singularity and intimacy then is appropriate in a nursing situation. For example, he suggests that 'the other for whom I care is a completion of my own being and as such is partially constitutive of my own personal identity. The other for whom I care is so important to me as to constitute an extension of my very self.'¹⁴ However, it seems less than realistic to expect that a nurse, no matter how dedicated, should form relationships with patients that are this intimate and self-defining. This is not to deny that part of the nurse's identity is constituted precisely by the activity of caring and by the various attitudes that are intrinsic to those activities. But it would be strange indeed if every person for whom the nurse cares were to enter into the selfhood of the nurse in this way.

Martin Buber¹⁵ for his part has made the now frequently alluded to (but not so frequently understood) distinction between an 'I–It' relationship and an 'I–Thou' relationship. The first of these is instrumental. As an extreme example one might suggest that the upraised hand of a policeman can be related to in precisely the same way as a red stop sign. There is certainly no necessity to relate to the policeman as to a person when one performs the appropriate response: namely, bringing one's car to a halt. It is tempting to read Buber as suggesting that the contrasting 'I–Thou' relationship is properly an interpersonal one. However a careful reading of his text indicated that this is not so. Most interpersonal relationships are of the I–It kind because they involve some degree of objectification of the other. Even lovers relate in ways marked by routine and patterned behaviour and hence of fixed identities, rather than by the quite extraordinary sense of depth and mystery that marks the I-Thou relationship. This latter relationship is very special indeed. It is marked by an encounter with something deep, mysterious and awe-inspiring. Any conceptualising of what this object of the relationship is limits it and turns it into an It. The Thou to which we relate must remain mysterious and transcendental to ordinary experience. Indeed, as his book progresses it becomes ever clearer that Buber is preparing the way for a description of a relationship to an ineffable God.

That there are privileged moments in human relationships in which elements of transcendence shine though and the relationship is transformed briefly into an I–Thou relationship does not obscure the point that, standardly, our relationships to persons are more mundane and ordinary. It is clear also that the sorts of human encounters that allow for this shining through of the ineffable and awe-inspiring mystery of spiritual being are of a quiet intimate and rare kind. While no human meeting prevents the possibility of such an encounter, it can hardly be expected or called for in such formalized relationships as that between nurse and client. Indeed, the final irony attaching to the appeal of so many writers on nursing to Buber's text is that in an afterward to the third edition, Buber himself argues that the I–Thou relationship is not only unlikely to be present in the healer-patient relationship, but ought not to be so.¹⁶

It would seem that the rare and intimate mutuality of which Mayeroff and Buber speak is more appropriate to a description of the relationship of people in love than to the caring exercised by a nurse. This point has been noticed by Ann Griffin, who distinguishes caring as 'seeing to the needs of x' from caring as 'being fond of x', where x is a person.¹⁷ We use the term 'care' in both senses. A dutiful daughter who cares for her ageing mother can be said to care for her in either sense. Moreover, she can be said to care for her in the first sense even though she might not care for her in the second. Perhaps caring for someone whom one is not fond of is neither as satisfying nor as satisfactory as caring for someone whom one does care for in that second sense, but clearly the two senses are distinguishable. It seems that caring for someone in the sense of being fond of them involves some feeling of affection which is not necessary merely to see to their needs. Of course it is not explicitly suggested by the authors mentioned above that what nurses need to feel for patients is affection. But they do seem to require some sort of feeling or motivation as an essential component of the practice of caring. For her part Griffin also shows this tendency by suggesting that a satisfactory nursing relationship generates in the nurse a gratitude for the personal expansion of human experience that the practice of caring brings with it, and through this 'a kind of love' for the patient which is different from affection.

Two spiritual or emotional elements which it does seem appropriate to seek in a nurse–patient relationship are compassion and communication. It may seem odd to refer to this last as a spiritual or emotional element, but I do so because communication is facilitated between people who relate to one another with a degree of empathy. As Gabriel Marcel puts it:

the person who is at my disposal is the one who is capable of being with me with the whole of himself when I am in need; while the one who is not at my disposal seems merely to offer me a temporary loan raised on his resources. For the one I am presence; for the other I am an object.¹⁸

To be present to someone in this way is to open channels of communication which are not available in more object-like relationships (of which my relationship to the signalling policeman mentioned above is the most extreme example). It seems clear that this being present to the patient is one of the features of a nursing relationship which the authors cited above are after. Sidney Jourard is one author who spells this out in a very sensible way when he urges nurses to come out from behind a professional manner; which is often adopted as 'character armour' in the face of suffering, and open themselves to the possibility of real communication with the patients in their care.¹⁹ Not only is real communication necessary in order to facilitate the flow of information about the patient's condition to the nurse, and the flow of information about treatment and therapeutic activity from the nurse to the patient, but it is also clear that the patient's recovery is often enhanced by the feeling of warmth and encouragement that a caring nurse can convey.

The question arises, however, whether these therapeutically necessary levels of communication should or can arise out of the deep spiritual rapport which our authors seem to require, or whether they can arise from more mundane and less intimate forms of interpersonal being such as compassion. The reason that this suggestion strikes a new note in my discussion is that compassion is not based upon a feeling of equality with the patient. Quite the contrary, it requires that the nurse recognizes the illness and suffering of the patient along with her own health and abilities. The feeling of compassion is at least partially based upon recognition of one's own power and good fortune in contrast to the patient. This contrasts with the attitudinal stances advocated by our authors, who in their talk of mutual growth and rapport seek to place nurse and patient on an equal footing. While this may be admirable from the point of view of an egalitarian humanism, it flies in the face of the obvious fact that the patient is ill and the nurse is well. The patient is in need while the nurse is there to provide what is needed. To say that it must be an objective of nursing to make the patient a participant in his or her own therapy and to encourage the patient to learn to take independent charge of his or her own health is in no way to deny that the nurse as care-giver stands in a superior position in relation to the patient as care-receiver. Compassion is at once the recognition of this superiority and the wish that equality will be re-established.

I should add that compassion differs from pity on just this last point. Whereas pity is content with the inequality what separates the object of pity from the person who feels pity, compassion seeks to overcome that difference by appropriate beneficent activity. Pity involves condescension whereas compassion seeks to promote equality even as it recognizes inequality.²⁰

Compassion may then be a feeling which it is appropriate for a nurse to have. On the other hand, it is important to note that not all of a nurse's activity concerns people who are suffering. Work in health maintenance and education is usually work with healthy people. Is therefore not obvious that compassion needs to be a central emotion in the working lives of all nurses. One might care for someone out of compassion or out of some other emotion, or out of no emotion at all.

One last point needs to be made about caring as it is described by our authors. It is interesting to note just how moralistic the authors we have cited can be. Watson, for example, argues that the 'formation of a Humanistic Altruistic Value System ... [is] ... the first and most basic factor for the science of caring'.²¹ It is clear also that the virtues that Mayeroff sees as central to caring constitute an ideal of moral human excellence. It would seem not extravagant to say that calling for 'care' as the central commitment of nurses is calling for a particular moral orientation on the part of n...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Preface
• Acknowledgements
• Part 1 Health Care, Virtue and Education
• Part 2 The Objects of Health Care
• Bibliography
• Index