“To look deep into your child’s eyes and see in him both yourself and something utterly strange, and then to develop a zealous attachment to every aspect of him, is to achieve parenthood’s self-regarding, yet unselfish, abandon. It is astonishing how often such mutuality had been realized – how frequently parents who had supposed that they couldn’t care for an exceptional child discover that they can. The parental predisposition to love prevails in the most harrowing of circumstances. There is more imagination in the world than one might think.”

Andrew Solomon, “Far from the Tree: Parents, Children, and the Search for Identity” (New York: Scribner, 2012).

In his most recent book, writer and lecturer Andrew Solomon describes a deep love that leads to redemption. His case histories describe parents becoming virtuous through the practice of caring. Solomon records both their loving and their suffering. He does not see caring, necessarily, as an inherent trait but rather sees virtue emerging from the act of caring. The philosophical study of caring and virtue is known as the “ethics of care.” This column considers the ethics of care in relation to our patients and their families.

‘Ethics of care’ origins

Care ethics emerged as a distinct moral theory when psychologist Carol Gilligan, Ph.D., and philosopher Nel Noddings, Ph.D., labeled traditional moral theory as biased toward the male gender. They asserted the “voice of care” as a female alternative to Lawrence Kohlberg’s male “voice of justice.”

Originally, therefore, care ethics were described as a feminist ethic. To drive home this point, the suffragettes argued that granting voting rights to (white) women would lead to moral, social improvements! The naive assumption was that women by nature had traits of compassion, empathy, nurturance, and kindness, as exemplified by the good mother. This is known as feminist essentialism. Taking this gendered view further, Nel Noddings states that the domestic sphere is the originator and nurturer of justice, in the sense that the best social policies are identified, modeled, and sustained by practices in the “best families.” This is a difficult position: Who decides on the characteristics of “best families?”

Practice of caring vs. ethics

The practice of caring can be described as actions performed by the carer, or as a value, or as a disposition or virtue that resides in the person who is caring. The following points summarize the current positions of philosophers who identify themselves as care ethicists.

• Care reflects a specific type of moral reasoning. This is the Kohlberg-Gilligan argument of male vs. female reasoning . Although care and justice have evolved as distinct ethical practices and ideals, they are not necessarily incompatible. As gender roles soften and gender as a concept becomes more blurry, care and justice can be intertwined. Reasoning does not have to be either justice based or care based.

• Care is the practice of caring for someone (Andrew Solomon’s case histories). This stance does not romanticize the practice of caring. This stance does not consider caring as a trait or disposition. This stance acknowledges the suffering and hardship in caring that can coexist with love. This stance points to the potential for individual spiritual and personal growth that can accompany caregiving. Andrew Solomon would agree to the notion of stages of caring (“Moral Boundaries: A Political Argument for an Ethic of Care,” New York: Routledge, 1994). These stages are: (1) attentiveness, becoming aware of need; (2) responsibility, a willingness to respond and take care of need; (3) competence, the skill of providing good and successful care; and (4) responsiveness, consideration of the position of others as they see it and recognition of the potential for abuse in care. The practice of caring is more of a daily reality than the abstract virtue.

• Care is an inherent virtue. This stance includes both feminist essentialism and feminist care ethics. In feminist essentialism, the process of moral development follows gender roles. The prototypical caregiving mother and a care-receiving child romanticize and elevate motherhood to the ideal practice of care. Feminist care ethicists avoid this essentialism by situating caring practices in place and time. They describe care as the symbolic practice rather than actual practice of women. Feminist care ethicists explore care as a gender neutral activity, advancing a utopian vision of care as a gender-neutral activity and virtue. Cognitive capacities and virtues associated with mothering, (better described as being associated with parenting), are seen as essential to the concept of care. These virtues are preservative love (work of protection with cheerfulness and humility), fostering growth (sponsoring or nurturing a child’s unfolding), and training for social acceptability (a process of socialization that requires conscience and a struggle for authenticity). This position also is reflected in Solomon’s ethics of care.

• Care is an inherent character trait or disposition. This stance understands care ethics as a form of virtue ethics, with care being a central virtue. There is an emphasis on relationship as fundamental to being, and the parent-child relationship as paramount. Virtue ethics views emotions such as empathy, compassion, and sensitivity as prerequisites for moral development and the ethics of care.

• Care as social justice and political imperative. One of the earliest objections to an ethics of care was that it valorized the oppression of women. Nietzsche held that those who are oppressed develop moral theories that reaffirm subservient traits as virtues. Women who perform the work of care often perform this care to their own economic disadvantage. A social justice perspective implies that the voice of care is the voice of an oppressed person, and eschews the idea that moral maturity means self-sacrifice and self-effacement. Care ethics informed by a social justice perspective asks who is caring for whom and whether this relationship is just.

When care ethics are applied to domestic politics, economic justice, international relations, and culture, interesting ideas emerge. Governments and businesses become responsible for support in sickness, disability, old age, bad luck, and reversal of fortune, for providing protection, health care, and clean environments, and for upholding the rights of individuals. A focus on autonomy, independence, and self-determination, which traditionally are seen as male traits, devalues interdependence and relatedness, which traditionally are seen as female values. Care ethics suggest that we replace hierarchy and domination that is based on gender, class, race, and ethnicity with cooperation and attention to interdependency. Interdependency is ubiquitous, and care ethics is a political theory with universal application. The practice of caring has no political affiliation; however, if we had founding mothers instead of founding fathers, would the United States be based more on ethics of care?

•The caring professions. The practice of caring is a practice that helps individuals meet their basic needs, maintain capabilities, and alleviate pain and suffering, so they can survive and function in society. Using this definition, the practice of care does not require any emotional attachment. Using this definition, the activity itself is a virtuous moral position. The health care professions mostly provide “services” rather than “care.” Is empathy a necessary ingredient for the practice of care? Many people believe so, and organizations such as the Watson Caring Science Institute (watsoncaringscience.org) are dedicated to putting the caring back into health care.

Meaning for the psychiatrist

When caregivers of patients with dementia were asked how they felt about caregiving, they responded positively. Caregiving felt good. Here is a listing of some their responses:

“Feeling needed and responsible.”

“Feeling good inside, doing for someone what you want for yourself and knowing I’ve done my best.”

“Being able to help.”

“To brighten her days.”

“I know he is being cared for the way he is used to.”

“I feel that she is loved and not alone.”

These caregivers were mostly spouses (61%), with an average of 3.1 caregiving years. Caregivers reported that their relatives were moderately disabled, but they perceived more reward than burden ( Int. J. Geriatr. Psychiatry, 2004;19:533-7 ). The caregivers’ quality of life also proved similar to those in an age-controlled normal community sample. So if caregiving can be carried out without significantly affecting quality of life, caregiving can be more rewarding than burdensome.

Questions for the family psychiatrist:

• How am I caring for my patients and their families?

• What does it mean to care rather than provide a service?

• How has my psychiatric training changed how I perceive caring? Do I now care in a different way?

• Has the way I care developed through my practice of caring?

• Where am I in the stages of caring?

• When does caring mean advocacy?

Questions to ask patients and their families:

• Do you experience reward in caregiving?

• Are there ways to sustain and enhance the satisfaction and reward of caring?

• How might you explore the practice of caring?

• Has caring been redeeming for you?

• Has caring brought individual growth for you, despite the hardships?

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). Some of the research for this article came from The Internet Encyclopedia of Philosophy .