The care perspective and autonomy

In this article I wish to show how care ethics puts forward a fundamental critique on the ideal of independency in human life without thereby discounting autonomy as a moral value altogether. In care ethics, a relational account of autonomy is developed instead. Because care ethics is sometimes criticized in the literature as hopelessly vague and ambiguous, I shall begin by elaborating on how care ethics and its place in ethical theory can be understood. I shall stipulate a definition of care ethics as a moral perspective or orientation from which ethical theorizing can take place. This will mean that care ethics is more a stance from which we can theorize ethically, than ready-made theory in itself. In conceiving care ethics in this way, it becomes possible to make clear that, for instance, a moral concept of autonomy is not abandoned, but instead is given a particular place and interpretation. In the final part of this article I will show how ‘relational autonomy’ can be applied fruitfully in the practice of psychiatric care. This revised version was published online in July 2006 with corrections to the Cover Date.     

Doing good: autonomy in the margins of welfare

The welfare systems in the global North has seen changes in professional care delivery systems in the margins of welfare, from care in large treatment institutions, to community care and, more recently, to care taking place in home spaces. Care and support are increasingly provided in the home of the service user through floating support and home visits. Drawing on empirical ethics, we aim to inquire into modes of doing good care during professional workers’ home visits by building on observations of service interactions taking place during these home visits in two different settings: that is, a mental healthcare unit performing home visits in the context of psychiatric care and a special-housing unit performing home visits in the context of homelessness services. We also build on interviews as retrospective reflections on service interactions. Drawing on these empirical materials, we ask what is considered as doing good in the margins of welfare and identify three ideal patterns: the relationality of care, the situatedness of care and the subject of care. Furthermore, these ideal patterns are connected to two different ideals of good care and conceptions of autonomy in care relations.     

The phenomenological ethics of K. E. Løgstrup – a resource for health care ethics and philosophy?

Abstract This paper gives a presentation and critical assessment of the phenomenological philosophy and ethics of the Danish theologian and philosopher K. E. Løgstrup (1905–1981). It is argued that although the ethics of Løgstrup contain valuable insights, an uncritical appropriation as the main source for a health care ethics or a philosophy of caring, is problematic. Løgstrup's philosophy contains a number of internal problems, and does not adequately deal with some problems raised by work in the modern health care setting.     

Three versions of an ethics of care

The ethics of care still appeals to many in spite of penetrating criticisms of it which have been presented over the past 15 years or so. This paper tries to offer an explanation for this, and then to critically engage with three versions of an ethics of care. The explanation consists firstly in the close affinities between nursing and care. The three versions identified below are by Gilligan (1982 ), a second by Tronto (1993 ), and a third by Gastmans (2006 ), see also Little (1998 ). Each version is described and then subjected to criticism. It is concluded that where the ethics of care is presented in a distinctive way, it is at its least plausible; where it is stated in more plausible forms, it is not sufficiently distinct from nor superior to at least one other common approach to nursing ethics, namely the much-maligned 'four principles' approach. What is added by this paper to what is already known: as the article tries to explain, in spite of its being subjected to sustained criticism the ethics of care retains its appeal to many scholars. The paper tries to explain why, partly by distinguishing three different versions of an ethics of care. It is also shown that all three versions are beset with problems the least serious of which is distinctiveness from other approaches to moral problems in health care.     

Virtuous eating: Landscaping the ethics of elder care with food

The paper invigorates the discussion on ethics of care in ‘care-ful geographies’ by highlighting the importance of thinking with ‘culture’ and its moral dimensions in filtering local ethics of elder care in China. More specifically, it illuminates how care, both as ethics and virtue, was manifested by a group of Buddhist older adults' appreciation of vegetarian eating in relation to the responsibilities for their own health and accompanying moral obligations. The conceptualization of ‘virtuous eating’ provides a hermeneutic cultural tool to interpret the shifting identifications with vegetarian eating, articulated as xiu lian (修練cultivation), fu bao (福報blessing) and ci bei (慈悲compassion), thus generating its analytical capacity in highlighting the reciprocity and relationality of care. The meanings associated with values and morality of vegetarian eating were enacting in forging new configurations of ethics of care within their self-therapeutic caring encounters.     

Empty ethics: the problem with informed consent

Informed consent is increasingly heralded as an ethical panacea, a tool to counter autocratic and paternalistic medical practices. Debate about the implementation of informed consent is constricted and polarised, centering on the right of individuals to be fully informed and to freely choose versus an autocratic, paternalistic practice that negates individual choice. A bioethical framework, based on a principle-led form of reductive/deductive reasoning, dominates the current model of informed consent. Such a model tends to abstract the process of consent from its clinical and social setting. By flashing out the social process involved when patients and healthy volunteer subjects consent to take part in clinical drug trials, this paper attempts to address the problem arising from the current 'empty ethics' model. My arguments are substantiated by qualitative interview data drawn from a study I conducted on the process of consent as experienced by participants in clinical drug trials.     

Empirical ethics in action: Lessons from two empirical studies in nursing ethics

Despite the burgeoning of publications in nursing ethics, only more recently has empirical evidence on nursing ethics been published. How nursing ethics can be empirically studied as well as enriched by empirical data will be the focus of this paper. Two empirical studies will be briefly presented and their contribution to ethics discussed. The first one is a quantitative research project about nurses' ethical behavior in daily practice. Using an adapted version of Kohlberg's theory of moral development, this study tried to describe and explore nurses' responses to ethical dilemmas in daily nursing practice. The second study attempted to describe the specificity of residential palliative care. A qualitative approach was used to explore and describe the processes that take place on an inpatient palliative care unit, and the experiences of patients, relatives and palliative care team members. The analysis of the value of both research projects for ethics underlines the power of empirical understanding in the relationship between research and ethics. The need for integration of both qualitative and quantitative research methodologies is argued.     

Choosing embryos: ethical complexity and relational autonomy in staff accounts of PGD

The technique of preimplantation genetic diagnosis (PGD) is commonly explained as a way of checking the genes of embryos produced by IVF for serious genetic diseases. However, complex accounts of this technique emerged during ethics discussion groups held for PGD staff. These form part of a study exploring the social processes, meanings and institutions that frame and produce 'ethical problems' for practitioners, scientists and others working in the specialty of PGD in the UK. Two 'grey areas' raised by staff are discussed in terms of how far staff are, or in the future may be, able to support autonomous choices of women/couples: accepting 'carrier' embryos within the goal of creating a 'healthy' child; and sex selection of embryos for social reasons. These grey areas challenged the staff's resolve to offer individual informed choice, in the face of their awareness of possible collective social effects that might ensue from individual choices. We therefore argue that these new forms of choice pose a challenge to conventional models of individual autonomy used in UK genetic and reproductive counselling, and that 'relational autonomy' may be a more suitable ethical model to describe the ethical principles being drawn on by staff working in this area.     

“Women's autonomy and pregnancy care in rural India: A contextual analysis”

Studies in low-income countries have shown that women's autonomy (i.e. the freedom of women to exercise their judgment in order to act for their own interests) influences a number of reproductive and child health outcomes, including the use of pregnancy care services. However, studies have not examined the full spectrum of pregnancy care services needed for safe motherhood and have not accounted for community context. This study analyzed data on women and their villages from the cross-sectional population-based National Family Health Survey-2 (1998–1999) of rural India to investigate whether women's autonomy (measured in the 3 dimensions of decision-making autonomy, permission to go out, and financial autonomy) was associated with the use of adequate prenatal, delivery and postnatal care. The findings indicate women's autonomy was associated with greater use of pregnancy care services, particularly prenatal and postnatal care. The effect of women's autonomy on pregnancy care use varied according to the region of India examined (North, East and South) such that it was most consistently associated with pregnancy care use in south India, which also had the highest level of self-reported women's autonomy. The results regarding village level factors suggest that public investment in rural economic development, primary health care access, social cohesion and basic infrastructure such as electrification and paved roads were associated with pregnancy care use. Improvements in women's autonomy and these village factors may improve healthier child bearing in rural India.     

Historical and Philosophical Reflections on Patient Autonomy

Contemporary American medical ethics was born during a period of social ferment, a key theme of which was the espousal of individual rights. Driven by complex cultural forces united in the effort to protect individuality and self-determined choices, an extrapolation from case law to rights of patients was accomplished under the philosophical auspices of ‘autonomy’. Autonomy has a complex history; arising in the modern period as the idea of self-governance, it received its most ambitious philosophical elaboration in Kant's moral philosophy. In examining the Kantian construction, it is evident that neither his universal moral imperative nor his rigorous application of self-legislated ethical action can sustain our own notions of moral agency in a pragmatic, pluralistic society. But the Kantian position is useful in highlighting that self-governance is not equivalent to ‘autonomy’, and this distinction defines the limits of autonomy in the clinical setting. A critique of Engelhardt's idea of ‘principle of permission’ is used to illustrate autonomy's eclipse as a governing principle for medical ethics. This revised version was published online in July 2006 with corrections to the Cover Date.     

Effects of performance-based reimbursement on the professional autonomy and power of physicians and the quality of care.

The key question addressed in this study is whether performance-based reimbursement in health care affects the professional power and autonomy of physicians, and if so, whether this has any consequences for the quality of care. This cohort study examines the period 1994-98 in 11 Swedish county councils. Four hundred and eighteen physicians were studied in Stockholm County Council, which has a performance-based reimbursement system, and in ten councils without such a system. The results show that professional power and autonomy are considered to be very limited in all councils, and that they have decreased during the period studied. Professional autonomy is, however, more limited in Stockholm. The limitations in Stockholm are more related to financial considerations, whereas the limitations in the other councils are more due to guidelines and lists of recommended drugs. Professional autonomy and power were found to be important determinants for quality of care, and the physicians in Stockholm estimated the quality of care lower than their colleagues in the ten other councils. Thus, our study suggests that the performance-based reimbursement system might fail to reach the desired results due to its negative impact on professional power and autonomy.     

A poststructural rethinking of the ethics of technology in relation to the provision of palliative home care by district nurses

Technology and its interfaces with nursing care, patients and carers, and the home are many and varied. To date, healthcare services research has generally focussed on pragmatic issues such access to and the optimization of technology, while philosophical inquiry has tended to focus on the ethics of how technology makes the home more hospital like. However, the ethical implications of the ways in which technology shapes the subjectivities of patients and carers have not been explored. In order to explore this, poststructural theory, in particular the work of Butler, Foucault, and Deleuze, is used to theorize the relationship between subjectivity and materiality as ethically mandated on producing rather than precluding the development of subjectivities in novel ways. This theoretical understanding is then utilized through a process of ‘plugged in’ as described by Jackson and Massie that aims to link empirical data, research, and philosophical inquiry. Through this process, it is suggested that power, which the empirical data demonstrate, is frequently exercised through medical discourses and restricts patients' and carers' ability to shape the material environment of the home as a place to live and be cared for in palliative stages of illness. Alternative discourses are suggested both from the empirical data as well as other research, which may offer patients and carers the possibility of reclaiming power over the home and their subjectivities. Finally, the dichotomy between the home and hospital, mediated via technology, is posited as being problematic. It is argued the dichotomy is false and should be moved away from in order to allow an ethical embrace of technology in palliative care.     

Patient autonomy in emergency medicine

Theoretical models for patient-physician communication in clinical practice are frequently described in the literature. Respecting patient autonomy is an ethical problem the physician faces in a medical emergency situation. No theoretical physician-patient model seems to be ideal for solving the communication problem in clinical practice. Theoretical models can at best give guidance to behavior and judgement in emergency situations. In this article the premises of autonomous treatment decisions are discussed. Based on a case-report we discuss different genuine efforts the physician can do to uncover treatment refusal and respect patient autonomy in an emergency situation. Autonomy requires competence and in emergency medicine time does not allow intimate exploration of patient competence and reasons for treatment refusal. We find that the physician must base her decision on a firm theoretical base combined with a practical and realistic view of the patient's situation on a case to case basis.This revised version was published online in October 2005 with corrections to the Cover Date.     

Feminist ethics and menopause: autonomy and decision-making in primary medical care

The construction of menopause as a long-term risk to health and the adoption of discourses of prevention has made necessary a decision by women about medical treatment; specifically regarding the use of hormone replacement therapy. In a study of general practitioners' accounts of menopause and treatment in Australia, women's 'choice', 'informed decision-making' and 'empowerment' were key themes through which primary medical care for women at menopause was presented. These accounts create a position for women defined by the concept of individual choice and an ethic of autonomy. These data are a basis for theorising more generally in this paper. We critically examine the construct of 'informed decision-making' in relation to several approaches to ethics including bioethics and a range of feminist ethics. We identify the intensification of power relations produced by an ethic of autonomy and discuss the ways these considerations inform a feminist ethics of decision-making by women. We argue that an 'ethic of autonomy' and an 'offer of choice' in relation to health care for women at menopause, far from being emancipatory, serves to intensify power relations. The dichotomy of choice, to take or not to take hormone replacement therapy, is required to be a choice and is embedded in relations of power and bioethical discourse that construct meanings about what constitutes decision-making at menopause. The deployment of the principle of autonomy in medical practice limits decision-making by women precisely because it is detached from the construction of meaning and the self and makes invisible the relations of power of which it is a part.     

Change in the control of health care systems in Europe Implications for professional autonomy

Major changes are taking place in European health care systems,especially those in the former communist countries. However,in Western European countries reorganization is also on itsway, guided by the rhetoric of deregulation and competition.This might lead to a convergence in the institutional controlof health care systems, although it appears that different pathshave been chosen by Eastern European health care systems andWestern national health services. It is argued that the implicationsof these changes for the professional autonomy of doctors differand this is influenced by the way health care changes tie upclinical autonomy and economical autonomy.     

Judging the ethics of qualitative research: considering the "ethics as process" model

Decision-making about the ethics of qualitative research is problematic where the research design is emergent, and the balance between risks and benefits for research subjects are difficult to ascertain prior to study implementation. The discourses of health/medical research ethics and those of social research are shown to be divergent and, furthermore, where ethics committees tie themselves to the health/medical model of ethical decision-making, qualitative research approaches can be disadvantaged. Having demonstrated the dual discourses and their relevance to qualitative research ethics, a critical review of current approaches to maximising the success of qualitative research proposals being considered for approval by ethics committees is undertaken. This leads to a call for a system of monitoring qualitative research so that the "benefit to risk" ratio is always on the side of benefit. This has implications for the ways in which ethics committees are organised and the ways in which they function.     

Education not training: the challenge of developing professional autonomy

The aims of this paper are first, to differentiate between education and training, emphasizing the importance of the former in the professional education of occupational therapists; and second, to outline some of the possible threats to professional autonomy. A focus on training may result in a level of education that cannot sustain professional autonomy. However, the establishment of proscribed and detailed, nationally controlled educational standards may also limit a profession. The latter may occur when cost‐containment is a major societal concern, focusing educational standards on training and measurable outcomes of professional practice. Copyright © 2000 Whurr Publishers Ltd.     

A pluralist view of nursing ethics

Abstract  This paper makes the case for a pluralist, contextualist view of nursing ethics. In defending this view, I briefly outline two current perspectives of nursing ethics – the Traditional View and the Theory View. I argue that the Traditional View, which casts nursing ethics as a subcategory of healthcare ethics, is problematic because it (1) fails to sufficiently acknowledge the unique nature of nursing practice; and (2) applies standard ethical frameworks such as principlism to moral problems which tend to alienate or undermine nursing ethical concerns. Alternatively, the Theory View, which aims to build an independent and comprehensive theory of nursing ethics, is also found wanting because it (1) fails to sufficiently acknowledge the heterogeneous nature of nursing practices; (2) overemphasizes the differences and undervalues the similarities between nurses and other health professionals; and (3) assumes that one ethical framework can be meaningfully applied across diverse moral problems and contexts.
My alternative, is to argue that nursing ethics inquiry should take a pluralist and critical stance towards available ethical frameworks and the negotiation of the ethical realm. On this view, the search for moral consensus or a unique ethical framework for nursing is replaced by the task of working strategically with multiple frameworks in order to expand the moral agency of nurses and empower them to positively engage with moral uncertainty as an inevitable feature of living a moral life. I conclude by indicating some of the implications that this has for the teaching of nursing ethics.