nursing – Medical and Health Humanities

June 28, 2017

Helen Kohlen

Interview with prof. dr. Helen Kohlen, Philosophical-Theological University of Vallendar (Koblenz) in Germany.

1. Where are you working at this moment?

I am working at the Philosophical-Theological University of Vallendar (Koblenz) in Germany. It is a small private university that has just been building up an ethics institute in which I am working as a co-director. I teach ethics and palliative care in the nursing faculty. Since 2015, a visiting professorship at the University for Humanistic Studies in Utrecht brought about a close collaboration with care ethicists in Utrecht.

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

My research addresses the ethics of care in the context of health care practices and the distribution of care work in society. Within this broad research field and having a background in Health Care Studies, English Literature, Political Science and Nursing I have a number different interests.

My first book Conflicts of Care (2009) was based on a field research in clinical ethics. I studied hospital ethics committees in the US and in Germany by foregrounding the development of Bioethics. I found out that the ethics of care has historically been marginalized as a theoretical approach to understand conflicts in clinical practice. Since the language of care is hardly used in German hospital ethics committees, conflicts that could have been represented from an ethics of care perspective tend to be sidelined and dismissed.

Based on the findings, in 2010 a participatory action research project was designed with the intention of developing a program that would empower professional health care actors to move ethics in practice by bringing in care ethical perspectives. I have recently completed a chapter for a new edited collection, Evaluation, Care and Society. It is edited by Merel Visse and Tineke Abma and will be published soon.
My chapter is called Evaluation for Moving Ethics in Health Care Services towards Democratic Care and addresses care ethics as an ongoing practice that involves learning process of democratisation. It describes a model that consists of the three pillars Education, Companionship and Open Space.

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

First, the ethics of care was a finding of my historical analysis ‘The move of bioethics to the bedside‘, seeing that the ethics of care appeared to be as a kind of counter-movement to US- American Bioethics in the 1980s.
Second, I read Elisabeth Conradi’s book ‘Take Care. Grundlagen einer Ethik der Achtsamkeit’ (2001) which I found very convincing. The book inspired me to read Joan Tronto’s book ‘Moral Boundaries. A Political Argument for an Ethics of Care’ (1994).

In 2006 I invited Joan Tronto to the University of Hannover in Germany and she had a lecture on the ethics of care and politics. Since then I have continuously been reading, writing and talking about the ethics of care. For example, I organized a conference (together with Hartmut Remmers) on Bioethics, Care and Gender and we published a collection of articles under this title (2010). In 2014 I coedited (with Gert Olthius & Jorma Heier) the book Moral Boundaries Redrawn. The Significance of Joan Tronto’s Arguments for Political Theory, Professional Ethics, and Care as Practice.

4. How would you define ethics of care?

I would define care ethics as a moral attitude and a set of practices that starts by seeing the human being as being basically dependent and vulnerable. The focus is the relational with regard to the concrete other and the concrete situation in time and space. In my studies I use care ethical questions within a critical lens to analyse what is missing in daily health care practices. These questions raise issues of conflict, power, inequality and irresponsibility.

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

I have learned that ethics can never be separated from politics and that doing care ethics in the health care arena can never be separated from doing political care ethics. I have also learned that the ethics of care is a movement of people who try to stand up against neo-liberalism.

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

Among the ones who have explicitly worked on the ethics of care I consider Carol Gilligan, Joan Tronto, Elisabeth Conradi, M.U. Walker, Annelies van Heijst, Eva Feder Kittay, Frigga Haug to be my most important teachers.

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

Carol Gilligan (1982): In a Different Voice, Psychological Theory and Women’s Development. Harvard University Press;
Joan Tronto (1994): Moral Boundaries, Political Argument for an Ethics of Care. Routledge;
Tronto, Joan (2013): Caring Democracy. Markets, Equality, and Justice. New York, London;
Elisabeth Conradi (2001): Take Care, Grundlagen einer Ethik der Achtsamkeit. Frankfurt am Main 2001;
Annelies van Heijst (2011): Professional Loving Care, An Ethical View of the Healthcare Sector. Peeters – Leuven;
Philips, Susan; Benner, Patricia (1994): The Crisis of Care, Affirming and Restoring Caring Practices in the Helping Professions. Georgetown University Press.

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

Helen Kohlen (2009): Conflicts of Care, Hospital Ethics Committees in the USA and Germany. Campus Verlag;
Hartmut Remmers & Helen Kohlen (2010): Bioethics, Care and Gender, Herausforderungen Fur Medizin, Pflege Und Politik (in German). V&R Unipress GmbH;
Olthuis, Gert; Kohlen, Helen; Heier, Jorma (2014): Moral Boundaries Redrawn. The significance of Joan Tronto’s Argument for Political Theory, Professional Ethics, and Care as Practice. Peeters Publishers 2014;
Kohlen, Helen: Care transformations – attentiveness, professional ethics and thoughts towards differentiation. Commentary, Nursing Ethics 18, March 2011: 258-261 (peer-reviewed);
Kohlen, Helen: Sorge als Arbeit und Ethik der Sorge – Verbindungslinien zwischen beiden wissenschaftlichen Diskursen. In: Conradi, Elisabeth; Vosman, Frans (2016): Praxis der Achtsamkeit: Schlüsselbegriffe der Care-Ethik. Fankfurt, New York: Campus, S. 193-225;
Kohlen, Helen: Sterben als Regelungsbedarf, Palliative Care und die Sorge um das Ganze. Ethik in der Medizin, 2016, 28(1), 1-4.

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

First, on a rather theoretical level, I think it is important to continue talking about the ethics of care and render visible what it can do in contrast to other theories.
Second, on a rather empirical level it needs to be shown what comes up when issues of concern are debated from a care ethics perspective as for example, in the area of bioethics, the debate about embryonic research.
Third, within the field of medicine and nursing it is important to refine the questions within an ethics of care for specific areas like neonatal care or dementia care.

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

I want to thank you very much for the excellent work you are doing in this area, currently, especially for organizing the Care Ethics Research Consortium.
From a teaching perspective I wonder, what could be done to distribute all the good work on the ethics of care that is already out there and I have the idea of writing a textbook for graduate students.
From a research perspective, I would be interested in a European Research Project on the Ethics of Care in Clinical Care.

March 28, 2013

Tula Brannelly

Interview with Tula Brannelly, Massey University, Wellington, New Zealand.

1. Where are you working at this moment?

I currently work at Massey University in Wellington, New Zealand in the School of Nursing. I have been at Massey since I emigrated from the UK in 2006. Previously I worked at the University of Birmingham, as a Research Fellow from 2003 – 2006 and was a PhD student there from 2000 – 2004.

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

My research is about facilitated participation and how people are enabled to participate in their own care. Broadly I am interested in the experiences of the implementation of health and social policies on marginalized groups, particularly older and younger people with mental health problems. My PhD, Citizenship and Care for People with Dementia, used ethics of care to understand how detention decisions were made with (or without) older people with dementia and their families.

More recently, I have considered drug and alcohol service provision for young people aged 12 – 16 in the same way. My current research, ‘Acts of Citizenship’ asks mental health service users and activists about influences on the outcomes of care, as well as identifying the issues that they think most need to change in practice as part of their change advocacy. Analysis in these projects uses care ethics to consider Tronto’s integrity of care and how that is experienced by people using services.

I have a practice background as a mental health nurse and that prompted my interest in the impact of care practices on people who use services. I once interviewed a nurse who had trained as I had in an asylum, and she recalled her training as a ‘catalogue of human rights abuses’. My research interest was shaped by my firsthand experience of seeing service provision as a lack of care, and equally that there are ample opportunities when care can happen.

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

When I began my PhD research I was thinking about how people with dementia have or do not have rights, but rights based approaches reinforce that people are not able to have rights rather than answer the problems of trying to provide good care. Marian Barnes, who was also at the University of Birmingham at the time, gave me a copy of Joan Tronto’s Moral Boundaries and I instantly recognized the power of care ethics when considering experiences of marginalization.

4. How would you define ethics of care?

Ethics of care surfaces the essential role of care in society, and this includes who does care and who benefits from that care, both paid and unpaid. Ethics of care can be used to examine classed, gendered and racialised aspects of care. Ethics of care also provides a critical framework by which the intentions and realities of care can be assessed. Broadly, it is able to challenge overvalued notions of independence and autonomy and this is long overdue to quell some of the ferocity of neoliberalism.

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

The most important thing for me about ethics of care is that it provides a coherent and applicable framework for the consideration of ethics in practice. When I first read Moral Boundaries, I wondered why I never knew about ethics of care as a practitioner. So, as well as my research area, I teach ethics of care to experienced practitioners and they instantly ‘get it’ about the usefulness of ethics of care to articulate why and how care needs to occur in practice. Beyond the analysis of care practices, ethics of care begins to demystify how care can possibly be so undervalued.

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

Joan Tronto for Moral Boundaries (1993) and I am looking forward to the next edition; Selma Sevenhuijsen for both Trace analysis and her 1998 book Citizenship and the Ethics of Care. Feminist Considerations on Justice, Morality and Politics; and most recently Marian Barnes’ latest book Care in Everyday Life (2012).

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

In addition to those listed above I welcome the plethora of new publishing in the area in the special issues in 2010 and 2011 of the journals Ethics and Social Welfare and Nursing Ethics. It was fabulous to see hem and Pettersen’s work about acute mental health care.

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

Many of my publications are about the experiences of people with dementia and their families and more are in development about, for example, how responsiveness may be practiced when working with people with mental health problems. Another area of interest is the commonalities of care ethics and values practiced in Māori centered practice. An edited book is planned from the Critical Care conference in Brighton UK in September 2012 with Marian Barnes, Lizzie Ward and Nicki Ward.

Brannelly T, Boulton A and Te Hiini A (2013) A relationship between the ethics of care and Māori worldview – the place of relationality and care in Maori mental health service provision, Ethics and Social Welfare, DOI:10.1080/17496535.2013.764001.
Brannelly, T. (2011). Sustaining citizenship: People with dementia and the phenomenon of social death. Nursing Ethics. 18(5), 662-671
Brannelly, P. (2011). That others matter: The moral achievement – Care ethics and citizenship in practice with people with dementia. Ethics and Social Welfare 5(2), 210-216
Barnes, M., & Brannelly, T. (2008). Achieving care and social justice for people with dementia. Nursing Ethics. 15(3), 384-395
Brannelly, PM. (2006). Negotiating ethics in dementia care: An analysis of an ethic of care in practice. Dementia. 5(2), 197-212

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

I would like to see more discussion within the group of care ethicists to see how the theory is used and what people think could be added to it, so an inward facing discussion. Also an outwards facing discussion is required to get others on board to demystify the importance of care, interdependence and a critical review of care and who is cared for. One struggle seems to be getting the message across about the political impact of considering democracy and care.

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

Thanks for the invite to contribute here and for the compilation of the other interviews which are fascinating. The Critical Care conference in September 2012 captured some of the current lively interest and dynamism about care ethics and the hope is to continue that conversation through the Global Care Ethics Network hosted on the website eSocSci. People with an interest in care ethics are invited to contribute to discussions about the development of care ethics and to spread the word about their work. If anyone wants to join the network please email me at p.m.brannelly@massey.ac.nz eSocSci aims to foster engagement at all levels of social science, and is live from April 12^th 2013.

May 11, 2011

Per Nortvedt

1. Where are you working at this moment?

I am working at The Center for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Norway.

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

I am conducting research into the foundation of care ethics, in particular questions concerning the role of emotions and moral sensitivity in moral judgments. Also I am engaged in metaphsyical questions concerning the basic motivations for care, particularly inspired by the ethics of Emmanuell Levinas. I call this ethics, an ethics of proximity: The Principle and Problem of Proximity in Ethics. (Journal of Medical Ethics 2008 (34).)

My works also pertains to the role of care and partiality in clinical health care priorities. The idea is that from the perspective an ethics of care there seems to follow a certain normative requirement to be partial. This role of partiality versus impartiality in ethics even though being heavily debated in moral philosophy has been scarcely addressed by care theorists, with some exceptions (Virginia Held, Joan Tronto, e.g). My idea is that an ethics of care, as well as an ethics of proximity can influence this debate in a constructive way.

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

As a nurse and in my PhDwork I was always interested in the role of moral sensitivity and empathy. During my PhD work I became increasingly interested in trying to establish a more solid normative basis for the role of emotions and empathy in moral judgments. Also my nursing background and research into how the historical tradition of nursing emphasised the phenomenology of illness and understanding the subjective experiences of the patient, greatly fueled my interest in an ethics of care and research into the foundations of care.

4. How would you define ethics of care?

The crucial focus of an ethics of care is on the importance of interpersonal relationships and the role of these relationships in moral judgments. An ethics of care takes place within interpersonal relationships to be of particular moral relevance to moral life and for moral judgments. In this respect two keywords of this ethics are: partiality – to give some particular attention to persons with whom one is interpersonally connected; and proximity – that personal closeness both relationally and in its spatio-temporality are morally significant.

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

That not only moral principles and moral judgment is what is central to morality and ethics. Also the role of moral sensitivity and moral motivation in which ones attitudes plays an important role is ethically and morally significant

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

The one I have been the most inspired by, even though he does not consider himself a care ethicist, is the american philosopher Lawrence Blum with his work on care and particularity in the 1980’s and the 90’s. Also the work of the norwegian philosopher Arne Johan Vetlesen and his work on empathy and moral performance have been of great influence to my own position.

Additionally, neither of them being care ethicist, but the philosophy of Emmanuell Levinas, the Norwegian phenomenologist and nurse philosopher Kari Martinsen and the American philosopher Samuel Scheffler with his work on associative duties and personal relationships has been a great inspiration in my career. Among leading care ethicists, I think the work of Joan Tronto, Virginia Held and the norwegian Tove Pettersen, in my view represent very solid work on care theory today.

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

Of course the seminal work of Carol Gilligan, but also the works mentioned by Tronto, Held and Tove Pettersen. Of special relevance for care ethics is Lawrence Blum, Moral Perception and Particularity, Cambridge UP 1994, and his Altruism, emotions and morality, Routledge, 1980. And Arne Johan Vetlesen, Perception, Empathy and Judgment, Penn State Press 1994.

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

My works that are most relevant and that I am most satisfied with is my PhD dissertation,: Sensitive Judgment Tano press Oslo 1996.

Care, Sensitivity and “the Moral Point of View”.. I: New Pathways for European Bioethics. Intersentia 2007 ISBN 978-90-5095-670-3. p. 81-99
Levinas, Justice and Health Care. Medicine, Health care and Philosophy 2003; Volume 6. s. 25-34.
Sensibility and Clinical Understanding. Medicine, Health care and Philosophy 2008; Volume11. s. 209-219
Subjectivity and Vulnerability; Reflections on the Foundation of Ethical Sensibility. Nursing Philosophy 2003; Volume 4.(5) s. 222-231
The Principle and Problem of Proximity in Ethics. Journal of Medical Ethics 2008 (34) s. 156-161
Most recent work: The ethics of care. Role Obligations and Moderate Partiality in Health Care. Nursing Ethics2011; Volume 18.(2) s. 192-200. Hem and Skirbekk co-authors
The Normativity of Clinical Health Care – Perspectives on Moral Realism. Forthcoming in the Journal of Medicine and Philosophy.

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

I think to clarify its normative potential and its distinctivess with relation to other theories like virtue ethics and consequentialist ethics. To accomplish this, it is increasingly important to set care ethics in play with the dominant perspectives and discussions within moral theory and philosophy. To mention some perspectives: Moral phenomenology, and metaphysics; Levinas, Husserl, Loegstrup. Analytical philosophy: Bernard Williams, Thomas Nagel, Samuel Scheffler, Christine Korsgaard. Moral realists and quasi-realists like Arne Johan Vetlesen, David Wiggins, consequentialists like Peter Singer, Peter Unger.

It is not satifying that an ethics of care can argue for the importance of relationships to moral life and judgments without in more detail discussing the normative implications of a relational view in ethics and morality.

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

I would very much like to be in more contact with you and would love to visit you, and perhaps have some joint seminars and projects.

April 8, 2011

Chris Gastmans

1. Where are you working at this moment?

I am working as full professor of medical ethics at the Centre for Biomedical Ethics and Law (CBMER) of the Catholic University of Leuven, Belgium. The Centre was created in 1986 (we celebrate the Centre’s 25th anniversary this year) at the medical faculty of our university. The Centre’s staff consists of moral theologians and philosophers, lawyers, nurses and psychologists. At the CBMER philosophical-ethical, empirical-ethical and legal research lines have been developed for reproductive medicine, genetics, biobanks, tissue transplantation, patient rights, end-of-life care and elderly care. We provide courses in medical ethics, healthcare ethics, nursing ethics, and medical law at all faculties of our university. These educational efforts have been translated in an Erasmus Mundus Master in Bioethics.

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

I am in charge of the research lines ‘elderly care ethics’ and ‘end-of-life care ethics’. These two major research lines contain research projects on nurses’ involvement in end-of-life care processes (e.g. euthanasia, withholding/withdrawing artificial food and fluid administration), ethical decision-making regarding physical restraints, intimacy and sexuality in institutionalized elderly, institutional ethics policies on euthanasia, etc. As you can see, all these topics are more or less closely linked to daily care practices. From the beginning of my research activities, I considered care ethics as a promising and innovative ethical perspective from which these care practices can be analyzed. However, as I am convinced that care ethics should go into dialogue with more fundamental theological and philosophical ethical theories, I also consider the personalist approach on ethics as an important source of my ethical thinking. Besides this philosophical-ethical approach to care ethics research, I also conduct empirical ethical studies that help me to understand the essential characteristics of ethically sensitive daily care processes.

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

I started my academic work in 1990 at the Centre for Biomedical Ethics and Law in Leuven. I got a doctoral degree in theology in 1995 with a critical study of the historical, anthropological, and moral theological foundations of nursing ethics, conceptualized as an ethics of care. Since 1998, I teach nursing ethics at the nursing department of the medical faculty, medical ethics at the faculty of theology and ethics of care at the faculty of philosophy. Recently, we initiated the international intensive course nursing ethics that will take place on December 7-9 2011 in Leuven. So it is clear that I was involved in the ethics of care from the very beginning of my academic career, both from a research and an educational perspective.

4. How would you define ethics of care?

Ethics of care stands for a unique normative perspective from which human behavior can be interpreted and evaluated. In order to have normative power, that is, to be able to distinguish between good and bad behavior, care ethics needs an explicit anthropological basis – a view of mankind that underlies care. This explicit anthropological basis helps us to clarify concepts closely related to care ethics such as vulnerability, interdependence, care, responsibility, relational autonomy, dignity, personhood. Only when the normative anthropological basis of care is sufficiently clarified care practices can be evaluated and optimized from an ethical point of view. I consider this as the main task of care ethicists.

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

The ethics of care provides many ideas that have deepen my insight into the essential characteristics of ethical problems, for instance the central role of vulnerability in human life. But the most important thing I learned from the ethics of care is the emphasis on the contextual embeddedness of ethically sensitive care practices. The role of context in care practices and its impact on the ethical quality of care practices can easily be made visible by empirical research using a qualitative design. For instance, the ethical reasoning of nurses when they are involved in care practices concerning the use of physical restraint in elderly care, is strongly influenced by contextual factors such as workload, time (day-night), architectural characteristics of the ward, communication culture among nurses and physicians. This also shows that the ethical quality of care practices can be improved by considering their contextual embeddedness.

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

When I was writing my PhD dissertation, I was strongly influenced by the writings of Lawrence Blum. His books ‘Friendship, Altruism and Morality’ (1980) and ‘Moral Perception and Particularity’ (1994) were very useful to clarify for instance the distinction between the virtue of care and emotional involvement. Regarding the personalist approach in ethics, I consider the Leuven moral theologian Louis Janssens as my most important teacher.

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

I would recommend the above mentioned books written by Lawrence Blum. But of course, my students are strongly motivated to read the well-known ‘Moral Boundaries’ of Joan Tronto. This book introduced really innovative perspectives in the ethics of care debate.

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

I would recommend ‘Nursing Considered as Moral Practice: A Philosophical-Ethical Interpretation of Nursing’, published in the Kennedy Institute of Ethics Journal, given that in this article, the main sources of my ethical thinking are brought into dialogue: nursing practice, care ethics, and personalism.

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

Most criticism towards the ethics of care concerns normativity (see for instance the thematic issue on care ethics in Nursing Ethics 2011 (2)). Hence, I think much more research should be done in order to strengthen the normative foundation of the care ethics approach. Therefore, it might be helpful to enrich care ethics by going into dialogue with the work of important philosophers as Emmanual Levinas, Maurice Merleau-Ponty, Martin Buber and Paul Ricoeur. These philosophers could help us to deepen the normative value of care by referring to its anthropological foundations (e.g. embodiment, intersubjectivity).

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

I appreciate the valuable work done by the colleagues. Different from our Centre in Leuven that is located at the medical faculty, the Tilburg care ethicists have very close links with theology and philosophy. I would support the efforts of the care ethicists to provide a sound philosophical and theological foundation for the ethics of care.