Medical versus care ethics

medical ethics

As a former medical student – but not a doctor – studying the field of care ethics, I was always interested in bringing these two worlds together. Whereas the dominant (bio)medical ethics in healthcare revolves around four principles – beneficence, non-maleficence, respect for autonomy, and justice – care ethics questions whether morality can be derived from abstract principles and suggests it rather emerges from relational practices. As a medical student I wasn’t even aware of an, or any, alternative brand of ethics. Was it just me or was my lack of knowledge a consequence of medical education and the profession I was briefly acquainted with?

My years as a medical student had left me with a negative stance towards medical education and health care practice in general, without actually being able to explain why. My negative feelings were corroborated by several (non-)scientific sources describing harm in the medical encounter. In 2011, Elin Martinsen ((Martinsen, E. (2011). Harm in the absence of care: Towards a medical ethics that cares. Nursing Ethics, 18(2), pp.174-183.)) attributed this harm to the dominant ethics in healthcare.

She pleads to include “care as a core concept in medical ethical terminology” because of “the harm to which patients may be exposed owing to a lack of care in the clinical encounter,” specifically between doctors and patients. She leaves the didactical challenges arising from such a venture open for further enquiry. This left me with a chance to tackle both my personal questions and fill a scientific gap.

The informal and hidden curriculum of medical education

In this paper, medical education in the Netherlands is investigated through a “care-ethical lens”. This means exploring the possibility of enriching medical education with care-ethical insights, while at the same time discovering possible challenges emerging from such an undertaking. We present an overview of what is written on medical education, we describe care-ethical theories and what implementing these theories into medical education would imply, and we consider the accounts of several authors on the subject of care ethics and medical education.[pullquote]Master Care Ethics and Policy, University of Humanistic Studies.[/pullquote]

Personally, I have learnt most from further investigating medical education. Several authors offer alarming insights into its unintended, educational effects. Besides a formal curriculum or the explicated learning objectives, an informal and a hidden curriculum are also described. The informal curriculum is about the interpersonal level of teaching and learning between teacher and student. The hidden curriculum is also about learning objectives, but, as its name suggests, hidden, unintentional, and implicit.

What is so alarming about this, is that these curricula can lead to the erosion of expectations, ideals, and personal traits in students. Several examples of erosion have been described, such as the loss of idealism, adopting a ritualized professional identity, emotional neutralization, change of ethical integrity, tolerance of abuse, and acceptance of hierarchy. Students become hidebound, focused on facts, emotionally detached, cynical, arrogant, and irritable. Important to note here is that erosion doesn’t occur in every medical student nor does it always happen to the same extent.

Enriching medical education

What do these hidden, unintentional, and implicit effects of medical education imply for the possibility of enriching medical education with care-ethical insights? By connecting the collected bodies of knowledge on both medical education and care ethics, possible challenges are identified which can be narrowed down to two: didactical and non-didactical. These challenges might be overcome through focusing more deeply on the clinical phases of training and creating awareness of the medical morality and all that is implicit among healthcare practitioners.

With care ethics, we are dealing with a different way of thinking, one that deviates from what is currently dominant within the medical field, as I quickly realized leaving that field. We should not underestimate the possible resistance to a paradigm shift.

Eva van Reenen, MA Care Ethics

Van Reenen, E. & Van Nistelrooij, A.A.M. (2017). A spoonful of care ethics: the challenges of enriching medical education. Nursing Ethics. doi: 10.1177/0969733017747956

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Raymond de Vries

Raymond de Vries

Raymond De Vries PhD co-directs the Center for Bioethics and Social Sciences in Medicine at the University of Michigan and is a Professor in the Department of Learning Health Sciences and the Department of Obstetrics and Gynecology there. He is also visiting professor at CAPHRI School for Public Health and Primary Care, University of Maastricht, the Netherlands. He is particularly interested in the regulation of science and the production of scientific knowledge; clinical trials of genetic therapies; the export of western moral traditions to non-western societies; and the social, ethical, and policy issues associated with the medicalization of pregnancy and birth.

1. Where are you working at this moment?

I am a sociologist, working at the bioethics program at the University of Michigan Medical School. I have appointments in the departments of medical education, obstetrics and gynaecology, and the department of sociology in the College of Literature, Sciences and the Arts.

2. Can you tell us about your research and its relation to the ethics of care?

My research is built on what I call a “sociology of bioethics” perspective. This means that rather than using my ability as a social scientist to answer questions generated by bioethicists (“sociology in bioethics”), I use bioethics as an arena for learning more about society, culture, and social organization. This approach naturally leads me to investigate different approaches to ethical reasoning – care ethics, principlism, feminist ethics, casuistry, etc. – with an eye toward understanding why and how these different strategies are used.

At the moment I am completing a book-length social history of bioethics and I am involved in a few research projects including, a study of the use of deliberative democracy to guide the creation of policy on surrogate consent for research and an interview study that is challenging existing ideas about the therapeutic misconception.

3. How did you get involved into the ethics of care?

As I explained above, I am interested in the different approaches to defining and resolving ethical dilemmas – how they have been developed, where they are used, who champions them. So my interest in care ethics (and its social location and social uses) begins there. My understanding of care ethics was greatly enhanced by a semester I spent at the Center for Law and ethics at the University of Leuven in the Fall of 2006. My great teachers there – Chris Gastmans, Kris Dierickx, Paul Schotsmans, Herman Nys, and Pascal Borry – introduced me to important nuances in the field.

4. How would you define ethics of care?

The ethics of care is an approach to seeing and resolving ethical problems that begins by understanding the individual and her social situation. Rather than an abstract approach that seeks to generalize about the nature and content of ethical problems, care ethics looks at moral problems in situ, seeking to understand and resolve these problems by recognizing how they are generated by (among other things) unequal relationships that derive from ideas about gender, ethnicity, and social class.

5. What is the most important thing you learned from the ethics of care?

I am not a well-versed student of Levinas, but his notion of the concept of l’autre – the other – and his insistence that the beginning of ethics is consideration of “the other” has given me a foundation on which to build an approach to (bio)ethics. Acting ethically in medicine, or in any sphere, requires attention and consideration of the other. Interestingly, this same idea is at the heart of principlism. The Belmont Report describes three principles: justice, beneficence, and respect for autonomy (not simply autonomy): this latter principle comes to close to the idea of Levinas in that it is asking that attention be paid to the (autonomy of) the other.

6. Whom do you consider to be your most important teacher(s) in this area?

Most important to me has been the work of Margaret Urban Walker. Her work on moral contexts, moral repair, and moral understanding (the titles three of her books) helped me (a social scientist!) to think more broadly and more clearly about the relational aspects of moral decision-making.

7. What works of in the ethics of care do you see as the most important?

Aside from the books by Walker mentioned above, I was inspired by Carol Gilligan’s, In a Different Voice. Long before I became interested in bioethics, this book got me thinking about how one’s situation in life shaped one’s moral sensibilities.

8. Which of your own books/articles should we read?

  • R. De Vries. How can we help? From ‘sociology in’ bioethics to ‘sociology of’ bioethics. Journal of Law, Medicine and Ethics, Vol. 32, No. 2, 2004: 279-292.
  • R. De Vries. Firing the neuroethical imagination. EMBO Reports. Vol. 8, 2007: S65-69.
  • R. De Vries. The Prepositions of Bioethics. Hastings Center Report, 38(3), 2008: 49.
  • R. De Vries, N. Berlinger, and W. Cadge. Lost in translation: the chaplain’s role in health care. Hastings Center Report, 38(6), 2008: 23-27.
  • R. De Vries. Why can’t we all just get along? A comment on Turner’s plea to social scientists and bioethicists. Cambridge Quarterly of Health Care Ethics. 18 (1), 2009: 43-46.
  • R. De Vries, Charles Bosk, Leigh Turner and Kristina Orfali (eds.). The view from here: Social Science and Bioethics. London: Blackwell, 2007.

9. What are important issues for the ethics of care in the future?

Ethicists must begin to think more about “upstream” solutions to ethical problems. At the moment, ethics is largely a reactive exercise, where one waits until an ethical dilemma arises and then struggles with a solution. Care ethics points us in a different direction: toward a way of thinking about the social and cultural conditions that are likely to generate ethical problems and then seeking to alter those conditions.

10. Our ambition is to promote ethics of care nationally and internationally. Do you have any recommendations or wishes?

Yes, how about organizing an international conference on “upstream bioethics?”